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[ { "category": "Echo", "chartdate": "2178-10-09 00:00:00.000", "description": "Report", "row_id": 69846, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. Preoperative assessment. Shortness of breath. Valvular heart disease.\nHeight: (in) 59\nWeight (lb): 140\nBSA (m2): 1.59 m2\nBP (mm Hg): 110/58\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 12:09\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo contrast in the\nbody of the LA. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA\nejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. 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. Normal aortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Characteristic rheumatic deformity of the mitral valve leaflets\nwith fused commissures and tethering of leaflet motion. Moderate mitral\nannular calcification. Mild valvular MS (MVA 1.5-2.0cm2). Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderately thickened tricuspid valve leaflets. No TS.\nModerate [2+] TR. Eccentric TR jet.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (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. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is moderately dilated. Mild spontaneous echo contrast is seen\nin the body of the left atrium. Mild spontaneous echo contrast is present in\nthe left atrial appendage. No thrombus is seen in the left atrial appendage.\nThe right atrium is dilated. No atrial septal defect is seen by 2D or color\nDoppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion.\nThere is no aortic valve stenosis. Trace aortic regurgitation is seen.\nThe mitral valve shows characteristic rheumatic deformity. There is mild\nvalvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation\nis seen.\nModerate to (2+) tricuspid regurgitation is seen.\nThe tricuspid regurgitation jet is eccentric and may be underestimated.\nThere is no pericardial effusion.\nDr. was notified in person of the results prior to incision.\n\nPOST-BYPASS:\n\nPreserved biventricular systolic function.\nThe prosthesis in the tricuspid position is stable and functioning well.\nThe mitral bioprosthesis is well seated and functioning well and mean\ntransmitral gradient is 3 mm of Hg.\nIntact thoracic aorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1212549, "text": " 3:03 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: post op evaluation, line placement, chest tube placement\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT; TVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p mitral valve replacement and tricuspid valve repair\n REASON FOR THIS EXAMINATION:\n post op evaluation, line placement, chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mitral valve replacement and tricuspid valve repair.\n\n FINDINGS: In comparison with the preoperative study, there are midline\n sternal wires in place and a prosthetic mitral valve. Endotracheal tube tip\n lies approximately 2 cm above the carina. Right IJ Swan-Ganz catheter\n probably is in the proximal portion of the left pulmonary artery. Nasogastric\n tube extends to the stomach. Right chest tube is in place without evidence of\n pneumothorax. Mild atelectatic changes are seen bilaterally. There appears\n to be a small component of mediastinal or pericardial gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1212769, "text": " 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hemothorax\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT; TVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with dropping HCT s/p MVR/Tvr\n REASON FOR THIS EXAMINATION:\n hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:28 P.M. ON \n\n HISTORY: Dropping hematocrit after MVR.\n\n IMPRESSION: AP chest compared to :\n\n Worsening consolidation at both lung bases medially is probably atelectasis.\n Pleural effusions are small if any. Heart size is top normal, but unchanged\n postoperatively. The appearance does not suggest intrathoracic bleeding.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1212649, "text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT; TVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p MVR, TV repair\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:53 A.M., \n\n HISTORY: Status post MVR and tricuspid valve repair. Question pneumothorax.\n\n IMPRESSION: AP chest compared to :\n\n Right jugular sheath is the only invasive device still in place, terminating\n at the origin of the right brachiocephalic vein. Mild-to-moderate left lower\n lobe atelectasis has worsened slightly. No pulmonary edema or pneumonia, no\n pleural effusion or pneumothorax is present. Mediastinum is not appreciably\n widened. Stomach is moderately distended with air.\n\n\n" }, { "category": "ECG", "chartdate": "2178-10-09 00:00:00.000", "description": "Report", "row_id": 153099, "text": "Sinus rhythm. Borderline low limb lead voltage. Vertical to borderline\nrightward QRS axis. Left atrial abnormality. Slight non-specific ST-T wave\nchange. Combination of findings, while non-diagnostic, may be seen with mitral\nstenosis, etc. Compared to the previous tracing of QRS axis is slightly\nmore rightward. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2178-10-13 00:00:00.000", "description": "Report", "row_id": 153097, "text": "Sinus tachycardia. Borderline P-R interval prolongation. Rightward axis.\nNon-specific T wave abnormalities. Since the previous tracing of the\nrate is faster. The axis is more vertical. T wave abnormalities are more\nprominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2178-10-11 00:00:00.000", "description": "Report", "row_id": 153098, "text": "Normal sinus rhythm. J point elevation in leads II, III, aVF and V5-V6.\nSmall non-diagnostic Q waves in leads II, III and aVF. There is Wenckebach\nblock. Compared to the previous tracing of the Wenckebach, Mobitz I\nheart block is new. Otherwise, no diagnostic interval change.\n\n" }, { "category": "Radiology", "chartdate": "2178-10-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1212661, "text": " 10:36 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 44cm left picc. tip?\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT; TVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 44cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:32 AM, \n\n HISTORY: New left PICC.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the left PICC line passes at least as far as the upper atrium where the\n tip is little indistinct, at least 3 cm below the estimated level of the\n superior cavoatrial junction. Aside from persistent left infrahilar\n atelectasis, lungs are clear. There is no pneumothorax or appreciable pleural\n effusion. Mediastinal caliber suggests distended mediastinal veins.\n\n Right internal jugular sheath ends at the junction with the right subclavian\n vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1213025, "text": " 11:04 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT; TVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo f s/p MVR and tv repair\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: MVR and tricuspid valve repair.\n\n IMPRESSION: PA and lateral chest compared to preoperative chest radiograph,\n and postoperative radiographs, through 23:\n\n Small bilateral pleural effusions are probably unchanged since .\n Left lower lobe atelectasis is mild, substantially improved. There is no\n pulmonary vascular engorgement or pulmonary edema. Borderline cardiomegaly is\n comparable to the preoperative appearance, but the left atrium is no longer as\n dilated. No pneumothorax.\n\n Left PIC line ends low in the SVC.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2132-12-14 00:00:00.000", "description": "Report", "row_id": 283008, "text": "Atrial fibrillation with moderate ventricular response. Q-T interval prolonged\nfor rate. Left ventricular hypertrophy. ST-T wave abnormalities which may be\ndue to left ventricular hypertrophy but cannot rule out ischemia. Compared to\nthe previous tracing of Q-T interval prolongation for rate is slightly\nmore marked. Otherwise, no diagnostic change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2152-09-25 00:00:00.000", "description": "Report", "row_id": 108672, "text": "Atrial paced rhythm. Since the previous tracing of no change.\nPreviously described abnormalities persist.\n\n" }, { "category": "ECG", "chartdate": "2152-09-23 00:00:00.000", "description": "Report", "row_id": 108673, "text": "Baseline artifact. Probable atrial paced and ventricular sensed rhythm\n(because of artifact cannot exclude A-V sequential pacing). Probable underlying\nleft bundle-branch block. Compared to the previous tracing of left\nbundle-branch block is new.\n\n" }, { "category": "Radiology", "chartdate": "2152-10-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883537, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA improvement? Pt with incr secretions today, failed RSBI.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o CHF, worsening PNA and hypoxia now s/p\n intubation .\n REASON FOR THIS EXAMINATION:\n PNA improvement? Pt with incr secretions today, failed RSBI.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:27 A.M., \n\n HISTORY: Worsening pneumonia and hypoxia.\n\n IMPRESSION: AP chest compared to and :\n\n Right upper lobe pneumonia had largely cleared by . Subsequently,\n a small region of consolidation has reappeared probably deposition of edema\n because there has been significant increase in diameter of the heart and the\n caliber of mediastinal veins in the interim. Elsewhere in the lungs, however,\n there is no edema. Nasogastric tube passes in the stomach and out of view.\n Tip of the endotracheal tube is at the upper margin of the clavicles nearly 8\n cm from the carina and 3-4 cm above optimal placement. Tip of the right\n subclavian line projects over the SVC. Atrial and ventricular pacer leads are\n in standard placements.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-10-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883452, "text": " 6:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o CHF, worsening PNA and hypoxia now s/p\n intubation .\n REASON FOR THIS EXAMINATION:\n evaluate infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST\n\n COMPARISON: .\n\n INDICATION: Hypoxia.\n\n An endotracheal tube remains in place, terminating approximately 5-1/2 cm\n above the carina. A nasogastric tube terminates below the diaphragm and\n permanent pacemaker and right subclavian catheter remain in satisfactory\n position. Cardiac silhouette is upper limits of normal in size. There is\n vascular engorgement and bilateral perihilar haziness. A previously present\n area of consolidation within the right upper lobe has cleared in the interval.\n There are possible layering pleural effusions bilaterally.\n\n IMPRESSION: Perihilar haziness in keeping with pulmonary edema. Interval\n resolution of right upper lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882924, "text": " 1:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT, OGT, infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o CHF, worsening PNA and hypoxia now s/p intubation.\n REASON FOR THIS EXAMINATION:\n eval ETT, OGT, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure, pneumonia, evaluate endotracheal tube\n and OG tube placement.\n\n COMPARISON: Chest x-ray from .\n\n SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: There is a right-sided\n cardiac pacemaker with leads in standard position. The endotracheal tube is\n 5.5 cm above the carina. The NG tube tip terminates in the upper stomach.\n Again seen is a right upper lobe opacity, which is unchanged in appearance\n since the prior study. There is mild congestive heart failure. There is a\n faint linear opacity at the left apex, which most likely does not represent a\n pneumothorax.\n\n IMPRESSION:\n 1. Mild congestive heart failure with opacification in the right upper lobe,\n which could represent asymmetric pulmonary edema, pneumonia, or aspiration.\n 2. Faint linear opacity at the left apex, which is likely not indicative of\n pneumothorax, and attention should be paid to this area on followup exams.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882682, "text": " 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval please for infiltrates, consolidations, or congestion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with pneumonia and CHF with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n Eval please for infiltrates, consolidations, or congestion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and CHF with worsening hypoxia.\n\n Compared with the previous film of there is significant\n increase in the area of air space consolidation in the right upper lobe\n consistent with progressive pneumonia. The heart is slightly enlarged. No\n definite CHF. Dual chamber left-sided pacemaker with atrial and ventricular\n leads in situ.\n\n IMPRESSION: Right upper lobe pneumonia, worse than on the prior study of\n . Probable old healed fractures of the right seventh and\n eighth ribs.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 882947, "text": " 4:53 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate R sc line\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o CHF, worsening PNA and hypoxia now s/p intubation.\n\n REASON FOR THIS EXAMINATION:\n evaluate R sc line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated for worsening pneumonia. Congestive heart failure. Status\n post right subclavian venous line placement.\n\n COMPARISON: 3.5 hours earlier on .\n\n FINDINGS: AP SUPINE PORTABLE VIEW. The new right subclavian central venous\n catheter terminates in the distal superior vena cava. There is no evidence of\n a pneumothorax in supine position. The endotracheal tube remains in good\n position, with tip approximately 6.5 cm above the carina. The nasogastric\n tube tip is in the proximal stomach, and its side port is above the\n gastroesophageal junction. The nasogastric tube should be advanced deeper\n into the stomach. The right atrial and right ventricular leads of the\n pacemaker in the left chest wall appear intact and in unchanged positions.\n Mild pulmonary edema appears unchanged. The right upper lobe pulmonary\n opacity is also unchanged.\n\n IMPRESSION:\n 1. Satisfactory position of the right subclavian central venous catheter.\n 2. The nasogastric tube should be advanced deeper into the stomach.\n 3. Stable mild pulmonary edema.\n 4. Stable right upper lobe opacity.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2152-09-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 882614, "text": " 9:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT FACIAL DROOP.R/O CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with weakness, L-sided facial droop by EMS report\n REASON FOR THIS EXAMINATION:\n r/o CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SUN 12:00 AM\n No hemorrhage. Old lacunes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old male with weakness in the left side by EMS report.\n Rule out CVA.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,\n shift of normally midline structures or hydrocephalus. The ventricles, sulci\n and basal cisterns are preserved. There are old lacunes in the left caudate\n and left thalamus, and an old left occipital lobe infarction. There are\n hypodensities in the periventricular white matter likely from chronic ischemic\n changes or old lacunes. This could mask an early infarction. There is\n calcification of internal carotid arteries. The - white matter\n differentiation is grossly preserved. There is opacification of a few right-\n sided ethmoid cells. The other visualized portions of the sinuses are normally\n aerated.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage.\n MRI would be more sensitive for detection of acute infarction.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2152-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882985, "text": " 6:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening consolidation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with pneumonia and CHF with worsening hypoxia .\n\n REASON FOR THIS EXAMINATION:\n Please eval for worsening consolidation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 6:29 A.M. ON \n\n HISTORY: Pneumonia and CHF. Worsening hypoxia.\n\n IMPRESSION: AP chest compared to :\n\n Severe right upper lobe pneumonia is unchanged. Mild interstitial edema has\n improved. be a second focus of consolidation in the juxta hilar, right\n middle or lower lobe, unchanged. Heart size top normal. No appreciable\n pleural effusion. Right lower lateral rib fractures are chronic. ET tube tip\n in standard placement. Tube caliber less than half the diameter of the\n trachea may be too small. Clinical correlation advised, as noted on previous\n reports. Right subclavian line tip projects over the SVC. Transvenous right\n atrial and ventricular pacer leads are unchanged in their expected positions.\n\n Nasogastric tube has been advanced into the stomach and out of view. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882840, "text": " 7:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, worsening infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with pneumonia and CHF with worsening hypoxia .\n\n REASON FOR THIS EXAMINATION:\n eval for CHF, worsening infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:54 P.M. ON \n\n HISTORY: Pneumonia, CHF, and hypoxia.\n\n IMPRESSION: AP chest compared to and 25:\n\n Severe right upper lobe pneumonia is unchanged, but there is small region of\n consolidation inferior to the right hilus that is new. Moderate cardiomegaly\n and pulmonary vascular engorgement persists. Right atrial and right\n ventricular transvenous pacer leads are continuous from the left pectoral\n pacemaker. There is no pneumothorax.\n\n Right-sided rib deformities suggest previous thoracotomy and rib resection.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882612, "text": " 8:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with weakness\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Weakness, query consolidation.\n\n COMPARISON: , chest x-ray.\n\n SINGLE UPRIGHT CHEST: Cardiac, mediastinal, and hilar contours are not\n significantly changed. There is a right upper lobe opacity. There are mildly\n increased pulmonary vascular markings indicating mild failure.\n Atherosclerotic aortic calcifications are again noted. There is a dual lead\n pacemaker on the left. Bony structures are unchanged.\n\n IMPRESSION:\n 1. Right upper lobe consolidation which may represent pneumonia versus\n aspiration.\n 2. Mild congestive heart failure.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-30 00:00:00.000", "description": "Report", "row_id": 1277518, "text": "micu/sicu nsg note: 19:00-7:00\nthis is a 77 y.o man with pacemaker av paced, ddd, h/o bradycardia, cri wtih baseline cr 1.9-2.1. pt adm with weakness s/p fall at home, chronic cough, adm to with pna confirmed via cxr. pt developed wosening hypoxia and was intubated on . vent settings were adjusted last eve wtih peep down to 8, fi02 remained at 40%, 14 rr, tidal volume 500. p02 was only 62 with abg done, thus peep resumed back up to 10.\n\nneuro: lightly sedated on propofol at 20mcg/kg/min. opens eyes to voice and follows simple commands. mae, bilat wrist restraints maintained to prevent tube from pulling out.\n\ncv: hr 60 av paced with no ectopy noted. bp ranging 130s-150s/40s-50s, +weak pp, +csm. given lopressor dose orded at 4am and tolerated well.\n\nresp: remains intubated on ac: fi02 40%, tidal volume 500, rr 14, 10 peep. previous abg on 8 peep was 7.34/59/62 with sats down to 92%. sating now 94-100%. sxn'd for small to moderate amts tan thick secretions.\n\ngi/gu: abd obese, firm, very distended but no change from yesterday. +bs, tolerating tube feedings nepro at goal rate of 50cc/hr with residuals 5cc. having small amts brown liquid stool via fecal inc. bag. foley patent draining >30cc/hr clear yellow urine after 500cc lr bolus was given at the beginning of the shift.\n\nskin: intact\n\nlines: r aline, r sc tlcl patent.\n\nendo: on insulin gtt which was shut off for 2 hours when bld sugar down in the 60s requiring amp d50. insulin gtt currently on at 5 units/hr.\n\nid: t max 100.8, continues on iv abx, temp defervesing down to 99.7.\n\nsocial: lives with wife and son. no contact from family this shift.\n\nplan: continue to monitor q1hr bld sugar and adjust insulin gtt as ordered, continue to wean off vent as tolerated, continue ivabx, continue to monitor temp and micro data. monitor u.o. and need for further ivf boluses. continue to replete lytes prn-k being repleted for am k of 3.4.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-30 00:00:00.000", "description": "Report", "row_id": 1277519, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support. Attempted to decrease the PEEP level from 10 cm to 8 cm, however, the abg results on 8 cm revealed a moderate hypoxemia. PEEP was returned to 10 cm PEEP. No repeat abg results at this time.\n\nNo RSBI measured due to the level of PEEP required.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-30 00:00:00.000", "description": "Report", "row_id": 1277520, "text": "Respiratory Care\n\n Pt continues on full ventilatory support. B/S sl coarse sx'ing pluggy thick tan secretions. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-26 00:00:00.000", "description": "Report", "row_id": 1277501, "text": "S/MICU Nursing Admission Note\n Pt is a 66y/o gentleman admitted on after falling at home x2, c/o generalized weakness, chronic cough, sometimes productive. denies fever,chills, in EW found to have pnuemonia by Chest Xray admitted to 11R.. treated on the floor with antibx, though Xray increasingly worsening and on evening pt became more hypoxic with O2 sat of 86-89% on 100% NRBreather. Admit to S/MICU for BiPAP and possible intubation.\n Allergies: NKDA\n PMH:CHF,CAD,HTN, Pacermaker DDD, IDDM, hyperlipedema,CRI, AS\n System Review:\n Respiratory: pt placed on mask vnetilation of , FIo2 100% rate 12-40 with minute ventilation of ABG 58/40/7.39 with O2 sat of 95% at time of drawing. BS coarse with diminished at the bases.\n Cardiac: given hx of CHF chest Xray is questionable for CHF, lasix 120mg given with minimal response. BP stable 120-140/70's HR 60 paced. no vea.\n GU: foley in place intially amber urine now light yellow. creat 2.5-2.8 baseline 1.9-2.2\n Neuro: a&Ox3, asking appropiate questions. MAE, interactive with care. tolerating mask ventilation well.\n Access: two perpheral lines in place.\n Plan: mask ventilation to avoid intubation. cont to monitor closely, diuresis as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-26 00:00:00.000", "description": "Report", "row_id": 1277502, "text": "altered resp status\nd:pt a&o x3 this am and able to follow simple commands appropriately. since pt has been intubated for continued hypoxia he has been effectively sedated on propofol gtt at15 mcg/kg/min and will titrate as needed for sedation and as his hemodynamics tolerate.\n\nresp: pt hia am was on bipap with io2 sats> 92% but o2 sats would quickly drop to high 70's when he would try to turn on his side and b/come disconnected form the vent. pt was placed on high flow o2 at 95% but his o2 sats continued to drop to 84-88% despite adding nc at 6l/m. his rr had been in the 20's but then began to climb to mid 30's. dr. to the bedside and decision made to intubate pt. anesthesia clalled and pt intubated with much difficuly using a cook catheter with a # 7.5 ett. pt presnetly on vent settings of 60%/600/ac14 with 18 peep and o2 sats> 98%. lungs essentially clear on auscultation but diminished at the bases. suctioned orally for lg amts of clear secretions and ett for sm amt of rust colored sputum. will continue vent as pt tolerates and as the r lung pneumonia improves.\n\n\ncb: pt av paced at rate of 60 without ectopy and sbp 90-120's. electrolytes wnr and will recheck in the am and repelte as needed.pt receivng his cardiac meds as ordered.\n\n\ngi: ogt in place and placement verified by cxr and auscultation. abd obese bit soft. pt incontinent of lg amts of brown soft stool and fib now in place. hct stable at 32.4\n\ngu: ? if pt is hypovolemic. pt now receiving maintenance ivf of d5 1/2 ns at 100cc's/hr and has also received of 1 1/2 liters of ns in fluid boluses for hypotension. if hypotension continues may need to add pressor.pt with cri and creat today=3.1 and bun=42.\n\nid: max temp=103.1 and pt had blood cultures sent off form aline and r cl. po flagyl d/c'd and she continues to receive levofloxacin and .vancomycin. pt medicated with 1 gm tylenol and will follow fever curve\n\nsocail: pt is a full code. his wife was in to visit as well as many of his daughters. will with present medical management and keep family well informed on a daily basis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-26 00:00:00.000", "description": "Report", "row_id": 1277503, "text": "Respiratory Therapy\n\nReceived pt on NIPPV this AM, pt tolerating well w/ SpO2 low 90s, however would quickly drop to 70s when turning on side causing mask leak. Pt switched to high flow neb @ .95% and 6LPM NC & continued to drop SpO2 to 80s. Decision was made by team to electively intubate for persistent hypoxia/resp failure. Anesthesia called. Pt was very difficult intubation requiring several attempts w/ LMA, then intubated w/ #7.5ETT over cook catheter. Still requiring high levels of PEEP. Possible candidate for esophogeal ballooon placement.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277513, "text": "Resp: pt on a/c 14/500/+14/50%. Bs are sl coarse with diminished bases. Suctioned for small amounts of white secretions. No changes noc. Sputum sample sent. AM ABG pending. Will continue full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-02 00:00:00.000", "description": "Report", "row_id": 1277527, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made througho0ut the night. No morning abg results at this time.\n\nPatient unable to tolerate RSBI measurement due to tachypnea (rr = 50).\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277514, "text": "micu/sicu nsg note addendum for 19:00-7:00\nam abg 7.33/38/147. md notified and fi02 weaned down to 40% and peep weaned down to 12. repeat abg: 7.33/40/84, sp02 holding at 97% with pt appearing comfortable. no further vent changes md. vanco held for level > 15.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277515, "text": "Nsg. Narrative\nEasily arousable and able to follow simple commands and MAE's as appropriate. Remains sedated with Propofol @ 20 mcg/kg/min. titrate as needed for sedation. Started insulin drip of 3 units @ 1100 d/t\n elevated BG fingersticks above 200. At 1300 his BG was 262 so increased insulin drip to 5 units. At 1400 increased drip to7 units(BG=199), At 1500 increased insulin drip to 8 units(BG=140) Drip rate remains at 8units. Started Lopressor @ 1600 d/t Sl. HTN and this was his normal med. prior to hospitalization.\n\nResp: Remains intubated on AC. Vent settings changed to: FiO2=40,\nPeep 12 then down to 10 with no desaturation noted, TV stayed at 500. O2 sats remained 99%. L/S slightly improved but remain coarse in all fields.\n\nCV: BP: 84-143/51-58; HR: Paced at 60 with no ectopy noted; T: 99.7-98.6. ABG: 7.33/40/84\n\nGU/GI: Abd. remains distended, soft. +BS all quads. OGT in place and verified by auscultation. Gave 2-50cc tube flushes. Fecal incontinence bag in place. Administered Colace today.. Foley patent, urine is yellow and clear. Also administered 2-500cc fluid bolus d/t a decrease in output. Bun=60, Cr=4.0 Cl=111\n\nIntegrity: In-tact, warm and moist\n\nPlan: Continue to wean resp support as tolerted, evaluate for extubation. Continue medical management, respiratory and hemodynamic parameters.\nKeep family informed daily. Family is very supportative . Patient is full code\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277516, "text": "Addendum to previous note\n-101.1...Administered 1 GM tylenol..\n\nPlan: Recheck T q 1 hr\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277517, "text": "Respiratory Care Note:\n Patient remains on A/C mode with decreased PEEP today-improving oxygenation. BS remain slightly coarse over RUL, RML, diminished bases. Suctioned for thick tan sputum. Et tube resecured. He is sedated on propofol but responsive and cooperative. Plan to continue supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-02 00:00:00.000", "description": "Report", "row_id": 1277528, "text": "RESP; PT. EXTUBATED AT 14PM WITHOUT DIFFICULTY. PLACED ON COOL MASK, BUT CHANGED TO 4L NP. PT. COUGHING AND RAISING THIN WHITE SECRETIONS AND USING THE YANKOR FREQUENTLY. O2 SATS 95%-98%. BS'S CLEAR PRIOR TO EXTUBATION, BUT PRESENTLY COARSE SOUNDING.\nGI: OGT REMOVED. TAKING WATER WITHOUT DIFFICULTY. RECTAL TUBE REMAINS IN, BUT CAN PROBABLY D/C THIS EVENING.\nRENAL: GIVEN 20MG LASIX IVP WITH EXCELLENT RESPONSE.\nENDOC: K+ REPLETED WITH LASIX. NA OF 151 BEING TX'ED WITH D5W AT 100CC/HR. INSULIN GTT D/C'ED AND ON SSI AND FIXED DOSE.\nID: LOW GRADE TEMP 99.4AX. CONT. ON ANTIBIOTICS.\nNEURO: VERY NEEDY POST EXTUBATION. WANTS TO BE TURNED Q1HR. WHICH I EXPLAINED WAS UNREASONABLE. ALERT AND ORIENTATED.\nCV: RESTARTED ON HIS CARDIAC MEDS. HEMODYNAMICALLY STABLE.\nPLAN: IF STABLE OVERNIGHT, PLAN IS TO C/O TOMORROW.\nACCESS: A-LINE AND TRIPLE LUMEN.\nSOCIAL: DAUGHTER INTO VISIT.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-03 00:00:00.000", "description": "Report", "row_id": 1277529, "text": "micu/sicu nsg note: 19:00-7:00\nclarification: sbp ranging 80s-90s with maps 60 or greater (not sbp in 140s-160s). ? sbp readings accurate md who stated bps weren't correlating when the aline was in place. when sbp runs low, pt has been sleeping and woken up with an improved sbp.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-03 00:00:00.000", "description": "Report", "row_id": 1277530, "text": "micu/sicu nsg note:\ndisregard the above note-written on the wrong pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-03 00:00:00.000", "description": "Report", "row_id": 1277531, "text": "micu/sicu nsg note: 19:00-7:00\nthis is a 77 y.o. man adm with weakness, s/p fall at home, with chronic cough, dev. worsening hypoxia with cxr revealing rul pna on . by pt was intubated. extubated and sating well on 4lnc coughing up alot of white thick sputum.\n\nneuro: a&ox3, mae, following commands appropriately. limits set for frequency of turns min q2hrs with pt adhering to schedule. pt up most of the night coughing, deep breathing and using his incentive spirometer.\n\ncv: hr 60 av paced with no ectopy noted. bp ranging 140s-160s/50s-60s. +weak pp, trace pedal edema, +csm.\n\nresp: lungs coarse t/o. + productive cough with small to moderate amts thick white sputum. using incentive spirometer very often with good technique. sp02 ranging 96-100% on 4lnc.\n\ngi/gu: abd firm, distended, nt, +bs, had small amt brown loose stool in rectal tube- removed. no further bm. tolerating sips water with pills but with + cough sometimes after taking sips water. pt denies choking on water and states he has been coughing alot just to get more phlegm up. foley patent draining clear yellow urine. pt approx even over last 24 hours and approx 10 liters +los.\n\n\nid: t max 98.6 ax, continues on ivabx\n\n\nskin: intact.\n\nlines: r radial aline and r tlcl patent.\n\nendo: elevated am bld sugar requiring ssri. given fixed dose in pm.\n\nplan: continue to enc. pt to cough and deep breathe and use the incentive spirometer, continue ivabx, monitor temp, ? call out to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-28 00:00:00.000", "description": "Report", "row_id": 1277511, "text": "Respiratory Care Note:\n Patient remains intubated and sedated on propofol. He appears comfortable and is responsive. He received a bronchoscopy today with BAL done from RML. Specimen sent to lab for cultures. Suctioned for minimal secretions. BS remain coarse t/o. Plan to continue with supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-29 00:00:00.000", "description": "Report", "row_id": 1277512, "text": "micu/sicu nsg note: 19:00-7:00\nthis is a 77 y.o. man adm with weakness, s/p fall at home, chronic cough found to have rul pna. pt with worsening hypoxia and was intubated by . negative cxs up to date.\n\nneuro: remains lightly sedated on propofol at 20mcg/kg/min. opens eyes to voice. able to squeeze my hand with both of his hands, wiggles toes. bilat wrist restraints maintained for safety to prevent pulling ett. follows simple commands and able to nod/shake head to yes/no questions.\n\ncv: hr 60 av paced with no ectopy noted. bp ranging 120s-140s/50s. +weak pp, +csm. trace pedal edema.\n\nresp: remains intubated on ac. vent settings unchanged: .5 x 500x 14 + 14. awaiting am abg results. sp02 ranging 98-100%. sx'd for small amts white colored thick sputum. sent for gm stain and cx.\n\ngi/gu: abd firm, obese, + hypoactive bs. tolerating nepro at goal rate of 50cc/hr with <5cc residuals. had 600cc brown loose stool. sent for cdiff. foley patent draining clear yellow urine. pt 1.6 liters + over last 24hrs,5.7l + over los. u.o. dropping down x1 to 28cc/hr and then picked up without intervention. u.o. down again at 4am and will continue to monitor closely as corrected cvp 14.\n\n\nskin: intact.\n\nendo: bs elevated covered with new ssri. (see med sheets/carevue for details.\n\nf/e/n: am k=3.5- repleted with 20 meq iv kcl. no ivf boluses given overnight.\n\nlines: l hand and r hand piv, r radial aline, and rsc tlcl patent.\n\nid: t max 100.6po. given 650mg tylenol with t current 99.7po. continues on iv abx, awaiting iv vanco level to see if pt can receive iv am vanco dose.\n\nplan: continue to monitor hemodynamic status, vent settings as ordered, maintain light sedation with propofol and wean off when close to extubation, continue iv abx, monitor micro data, replete lytes prn, continue tube feedings at goal rate of 50cc/hr, monitor bld sugars with ssri, f/u with bronch results, f/u with vanco level results.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-10-01 00:00:00.000", "description": "Report", "row_id": 1277525, "text": "altered resp status\nd: pt sedated on propofol gtt at 20 mcg/kg/min and pt remains easily arousable and able to follow simple commands. this afternoon propofol gtt d/cd with ? of extubation and pt totally awake. decision made not to extubate pt till the am and propofol gtt was restarted at 40mcg/kg/min and will stop sedation at 0700.\n\nresp: remains orally inutbated .pt with adequate rsbi and changed to cpap mode of ventilation. pt then on sbt and tolerated well but pt with increased amts of thick tan sputum via ett and orally for copious amts of clear secretions. because pt was an extremely difficult intubation requiring the use of the cook cath, anesthesia has requested that pt not be extubated till the am. pt now on 40% cpap with 5 peep and ips of 10 with o2 sats>97%. coarse bs bil on auscultation. will resume vent weaning in the am andw ill beextubated when anesthesia is able to be present at the bedside,\n\ncv: hemodynamcially stable. hr 60 vpaced and sbp 124-157. hypokalemic and pt repleted as ordered. will recheck electrolytes in the am and replete as needed.\n\ngi: ogt in place and pt receiving tube fdgs of nerpo at goal rate of 50cc's/hr with minimal residuals. abd firm and distended with pos bowel sounds on auscultation. rectal mushroom cath in place with approx 300cc's liquid brown stool. hct stable at 29.3. pt on insuln gtt at 4 u/hr and blood sugars as documented in care view.\n\ngu: foley cath in place with adequate hourly uo. bun=46 and creat=2.6. i&o neg 180 cc's for this shift and for los pos 7.5 liters.\n\nid: max temp=98.6 and wbc=9.5. pt received 1 gm iv vnaco for level of 15.7.\n\nsocial: pt is a full code and will continue with present medical management. hope for extubation in the am. will continue to keep family well informed on a daily basis.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-02 00:00:00.000", "description": "Report", "row_id": 1277526, "text": "Nursing notes (1900-0700) 04:15\n\n\nNeuro.\nPt well sedated on 40mcg/kg/min of Propofol this shift, opening eyes to voice/stimuli only, only small amount of limb movement noted, appears to be comfortable. Sedation to be stopped at 0700 for possible extubation today.\n\n\nResp.\nNo Vent changes overnight, SpO2 98-100%, LS coarse to all fields with moderate amounts of thick white secretions by Sx Q3-4hrs.\nPt is for ??extubation with anesthesia present as pt is very difficult intubation should he fail.\n\n\nCVS.\nHR 60's AV Paced with no ectopy noted, K+ 3.3 this am, repleated with 40meq K+.\nBP 130/60's stable, on low dose lopressor.\nD5W at 100cc/hr and free H2O boluses for hypernatremia, this am Na151.\n\n\nGI/GU.\nTF's at goal of 50cc/hr with no residuals. +BS with liquid brown stool passed via rectal tube. Abd remains firm distended.\nGood amounts of urine passed via foley, BUN and Creat improving.\n\nEndo.\nPt remains on insulin gtt at 5 IU/hr, FSG wnl.\n\nSkin.\nAll pressure areas intact at present.\n\nSocial.\nNo contact from family this shift.\n\nPlan.\nStop sedation at 0700.\n?? extubate.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-27 00:00:00.000", "description": "Report", "row_id": 1277507, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Vt dropped to 500cc to promote ARDSnet protective lung strategy. All other vent parameters remain unchanged. BS coarse R side, slightly diminished w/ good aeration on L. Lavaged w/ N/S and suctioned for moderate amounts of thick yellow blood tinged sputum. SpO2 remained 90s on +16PEEP. See resp flowsheet for specifics.\n\nPlan: maintain full support\n" }, { "category": "Nursing/other", "chartdate": "2152-09-28 00:00:00.000", "description": "Report", "row_id": 1277508, "text": "Resp: pt on a/c 14 500/+16/50%. BS auscultated reveal bilateral coarse sounds which improved following suctioning. Suctioned for small amounts of thick yellow secretions. Vent changes to decrease peep to +14. ABG 7.41/38/61/25 with additional pending. Will continue full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-28 00:00:00.000", "description": "Report", "row_id": 1277509, "text": "S/MICU Nursing Progress NOte\n Pt is 77y/o gentleman admitted on for weakness,falling x2 at home, found to have pnuemonia by Chest Xray. Admitted to 11R when on increasing SOB,hypoxic despite 100% NRB, attempted mask ventilation overnight, pt was comfort on the mask ventilation with O2 sat 94-96%. ABg still showed hypoxia. intubated on afternoon of .\n System Review:\n Resp: intubated on vent with settings of A/C 500cc x 14 PEEP 16cm weaned down to 14cm suctioned q4hr for minimal thick sticky clear secretions. BS coarse throughout.\n Cardiac: HR 60 AVpaced, BP stable. art line is postional,\n ID: afebrile, cont on vanco(level from 1700 down to 16.5) and levoquin\n GU: foley in place, urine output fair averaging 50-80cc/hr. cont on NS at 100cc/hr. cont to be 3liters +for LOS,\n GI: on TF of Nepro inially on 20cc/hr low residuals increased to 30cc/hr. with increase in feeding pts' FS have been 200's all night. recieved 4units of humalog at 12am and 6am. ?need to adjust scale.\n Neuro: pt is sedated on propofol, able to wake to name, nod to yes/no questions, then able to drift off to sleep. MAE,\n Plan: cont to support, monitor cultures. wean when able follow I&O's closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-28 00:00:00.000", "description": "Report", "row_id": 1277510, "text": "MICU Nsg Note\nEasily arousable and able to follow simple commands and MAE's as appropriate. Lightly sedated with Propofol @ 20mcg/kg/min. Titrate as needed for sedation.\n\nResp: Remains intubated on AC. Vent settings FiO2=50, TV=500, PEEP decreased to 14 with no desaturation noted. O2 sats remain @ 99%. Coarse lung sounds in all lobes. Suctioned ETT, but unable to illicit any sputum. Bronch performed and levage fluid sent for culture.\n\nCV: BP: 99-154/42-55, HR: Paced at 60 with no noted ectopy,\n T: 103-99.5, Hct=29.9. Cultures sent after temp spike this AM.\n\nGU/GI: Abdomen remains distended, soft and +BS all quads.\nOgt in place and verified by auscultation. Nepro increased to 40cc/hr. Minimial residual throughout day. Goal is 50cc/hr. Fecal incontenance bag in place. Foley patent, urine is yellow and clear. Sent for culture after temp spike. Gave 500cc bolus due to decreased urine output. Bun=50, Cr=3.4 Cl=111\n\nINTEGRITY: in-tact, warm and moist\n\nAlteration in breathing pattern r/t pneumonia\nHigh risk for infection r/t invassive lines, ETT and foley\n\nPlan: Continue to monitor resp. and hemodynamic status. Continue respiratory support as needed. Increase tube feed as tolerated to reach goal of 50cc/hr. Continue medical management and keep family informed on daily basis. Patient is full code. Family visits and is very supportative.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-09-27 00:00:00.000", "description": "Report", "row_id": 1277504, "text": "S/MICU Nursing Progress Note\n pt is a 61 y/o gentleman admitted for weakness,falling at home, Chrst Xray showed pnuemonia, transferred from 11R on with increasingly hypoxic, and increase O2 requirements. Was on mask ventilation for 12hours without improvement in oxygenation. intubated on .\n Respiratory: intubated on the vent with settings of A/C 600cc x 12 PEEP of 18cm able to wean to 16cm. minimal secretions. BS coarse throughout. O2 sat 98-100% was 92-94% earlier in the evening.\n Cardiac: HR 60 paced. BP 110-120/70's no futher episodes of hypotension. cont to received NS at 100cc/hr minimal output... presently is +1600cc LOS, held antihypertensives as pts' BP 96-100/ at the beginning of evening.\n GU: foley in place, more water to balloon as possible leak.\n GI: ? placement of NGT, good sounds with asculation however had episode of once infusing fluids and coming back out mouth no stool\n Neuro: sedated on propofol, able to nod to yes/no questions, MAE, follows commands and is assisting in turning. bolused with 3cc of propofol x 2 each after activity.\n ID: temp down to 99-98 orally. cont on levoquin and iv vancomcyin.\n Social: daughter called updated by RN,\n Plan: awaiting culture results. antibx, wean vent accordingly. sedation to keep comfortable.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-27 00:00:00.000", "description": "Report", "row_id": 1277505, "text": "Resp Care\nPt. remains intubated/sedated with propofol. PEEP/fio2 weaned overnight (see careview for details).\nBS: coarse bilat. sxn'd x2 for sm-mod. blood tinged white thick. Changed over to heated circuit to improve sputum clearance.\nabgs: this morning within acceptable parameters.\nPlan: Cont. current support.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-27 00:00:00.000", "description": "Report", "row_id": 1277506, "text": "Narrative- altered resp status\nAwake, alert and able to follow simple commands appropriately and mae's. Effectively sedated with propofol@20mcg/kg/min.Will titrate as needed for sedation. Temp 98.7-101.7\n\nResp: Remains intubated on AC with vent settings: PEEP=16. FiO2+50, TV=600, but changed to TV=500 with no desaturation noted. rr rate set at 14. O2 Sats remained 99-100%. Coarse lung sounds in all lobes. Suctioned ETT for small to moderate thick yellow to blood tinged sputum and orally for copious clear secretions.\n\nCV:bp 108-148/48-56, HR:paced@60 with no noted ectopy . Checked HCT at 1600. Plan to transfuse for Hct<25.with elevated temp to 101.7 orally sbp dropped to 85 and pt given 500cc ns bolus x1 with good effect.\n\nGI/GU: Abd. grossly distended, soft. +BS all quads. OGT in place and verified by CXR and auscultation. Started Nepro at 1400 with rate of 10cc/hr. Goal is 50cc/hr. Foley patent, amber/sl. cloudy-sent for Eosinophill Count.Changed meds to be given down OGT . Fecal intontinence bag in place. BUN=51, Creatinine increased to 3.7 I/O for LOS +2.6L and for X12 hrs. +1.3L\n\nIV access: L arterial aline, R subclavian triple lumen, R hand peripheral 22 g. No redness, swelling or increase in skin temp.\\\n\\\nSkin: remains intact, warm and moist\n\n\nNsg Dx: Alteration in breathing pattern r/t pneumonia\n Risk for infection r/t invasive lines, ETT and foley\n\nPlan: Continue to monitor respiratory and hemodynamic status. Continue resp. support as needed and follow micro data. Continue plan for extubation. Increase tube feedings as tolerated. Continue with present medical management and keep family informed on daily basis. Pt. is a full code. Family in to visit and very supportative.\n" }, { "category": "Nursing/other", "chartdate": "2152-09-30 00:00:00.000", "description": "Report", "row_id": 1277521, "text": "altered resp status\nd: neuro: pt effectively sedated on propofol gtt at 20 mcg/kg/min and easily arousable. with present sedation pt is able to follow simple commands appropriately.\n\nresp: remains orally intubated and no vent changes made today. vent settings are 40% /500/ac 14 with 10 peep and o2 sats> 97%. coarse be bil on auscultation. suctioned for thick yellow sputum with plugs and orally for copious clear secretions. will continue to vent as pt tolerates.\n\ncv: hemodynamically v ery stable with hr 60 vpaced and sbp by r radial aline 97-145. electrolytes wnr and will recehck labs in the am and replete as needed.\n\ngi: pt with ogt in place tolerating tube fgds of nepro at his goal rate of 50cc's/hr with minimal residuals. abd firm and distended with pos bowel sounds on auscultation. mushroom cath in place with 200cc's loose brown stool outpu. hct stable at 28.4 insulin gtt infusing at 4u/hr and will continue to check blood sugars q1-2 hrs and titrate as needed.\n\ngu: foley cath in place with adequate hourly uo. bun=57 and creat=3.4. i&o pos 300cc's for this shift and pos 7.6 liters for los. follow fluid status closely.\n\nid: max temp=99.2 orally and wbc=10.7. pt continues to receive unasyn and vancomycin as ordered.\n\nsocial: pt is a full code. family was in to visit today and were updated on pt's status. will continue with present medical management and keep family well informed on a daily basis\n" }, { "category": "Nursing/other", "chartdate": "2152-10-01 00:00:00.000", "description": "Report", "row_id": 1277522, "text": "Nursing note (1900-0700) 04:30\n\n\nNeuro.\nPt remains lightly sedated on 20mcg/kg/min of Propofol, pt opening eyes to voice, and at times spontaneously. Pt moving all limbs with normal power, mouthing words around ETT.\n\nResp.\nNo vent changes made overnight, LS remain coarse to all fields, sx'd for thick white secretions Q4hrs. ABG pending. SpO2 97-100%.\n\nCVS.\nHR 60 AV Paced with no ectopy.\nBP 130's/70's on low dose Lopressor.\n\nGI/GU.\nTF's continue at goal of 50cc/hr with minimal residuals, +BS with moderate amount of liquid brown stool passed via rectal tube.\nGood amounts of yellow/cloudy-clear urine via foley.\n\nEndo.\nInsulin gtt remains at 4units/hr with FSG in 100's stable.\n\nSkin.\nPt's skin remains intact, all pressure areas wnl.\n\nSocial.\nFamily called for update by phone, plan to visit during the day.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-10-01 00:00:00.000", "description": "Report", "row_id": 1277523, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a partially compensated respiratory acidemia with good oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2152-10-01 00:00:00.000", "description": "Report", "row_id": 1277524, "text": "Resp care\n\nPt began day on A/C. Peep was weaned to 5 and RSBI performed and result was 82. Placed on SBT for 1 hr. MD's decided to wait until to attempt extubation. Pt did have cuff leak but had increase in secretions\n" } ]

[ { "category": "Radiology", "chartdate": "2200-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784215, "text": " 5:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check iabp placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with cad preop for cabg\n REASON FOR THIS EXAMINATION:\n check iabp placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 74 year old male awaiting CABG. Assess intraaortic\n balloon pump placement.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: None.\n\n FINDINGS: There is an intraaortic balloon pump with its tip located\n excessively distal at the level of the aortic arch. This should be withdrawn\n by approximately 4 cm. The lungs are clear, with no confluent areas of\n opacification. There are no pleural effusions.\n\n IMPRESSION:\n Placement of intraaortic balloon pump at the level of the aortic knob.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 784881, "text": " 9:53 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p CABGx5\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n Compared to 4 days earlier.\n\n INDICATION: S/P coronary artery bypass surgery.\n\n There has been interval median sternotomy and coronary artery bypass surgery.\n Cardiac and mediastinal contours are within normal limits for postoperative\n status of the patient. There has been interval development of left lower lobe\n atelectasis. There is also some minor atelectasis at the right base. Small\n pleural effusions are seen bilaterally. No pneumothorax is evident.\n\n IMPRESSION: Left lower lobe atelectasis and small pleural effusions following\n coronary artery bypass surgery.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784515, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: IABP PLACEMENT D/T URINE OP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with cad preop for cabg\n\n REASON FOR THIS EXAMINATION:\n IABP PLACEMENT D/T URINE OP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative chest evaluation prior to CABG.\n\n TECHNIQUE: Portable AP supine chest radiograph.\n\n COMPARISONS: \n\n FINDINGS: There is an intra aortic balloon pump with the tip approximately\n 2.6 cm from the roof of the aortic knob. The cardiac and mediastinal contours\n are stable. There is slight unfolding of the aorta. The pulmonary vasculature\n is not engorged. The lungs are clear. There are no pleural effusions. The\n visualized osseous structures and soft tissues are unremarkable. Please note\n the right costophrenic angle is excluded from this examination.\n\n IMPRESSION: No acute cardiopulmonary abnormalities.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-14 00:00:00.000", "description": "Report", "row_id": 1341259, "text": "NEURO WAKING PROPOFOL OFF MS FOR PAIN FOLLOWS COMMANDS LETHARGIC BUT RESPONSIVE SLIGHT AGITATION IMPROVED WITH MS NODS YES FOR PAIN WITH RELIEF\n\nC/V IMPROVED B/P WITH WAKING NEO OFF TOL WELL\n\nPLAN CONTINUE TO WEAN AS TOL EXTUBATE TONOC WHEN FULLY AWAKE AND WEANED\n" }, { "category": "Nursing/other", "chartdate": "2200-02-15 00:00:00.000", "description": "Report", "row_id": 1341260, "text": "NEURO-REVERSALS GIVEN PRIOR TO SHIFT START.PT AWAKENS TO VOICE,FOLLOWS COMMANDS,MAE.CALM/COOPERATIVE WITH CARE.\n\nCV-NSR 70-80 NO ECTOPY. CO/CI>2.5 PA/CVP WNL.NEO WEANED TO OFF. IABP WEANED 1:2->1:3 WITH STABLE HEMODYNAMICS.\n\nRESP-EXTUBATED WITHOUT INCIDENCE TO 50% WITH SATS MAINTAINING> 98%. STRONG PRODUCTIVE COUGH AFTERWARDS. LSC,DIM AT BASES. WEANED TO 3LNC , SAT98%. CT DRGING SCANT THIN SANG FLUID.\n\nG.I.- SOFT. + BS. ICE CHIPS STARTED.\n\nG.U.- FOLEY WITH ADEQ. AMT CLEAR YELLOW URINE.\n\nENDO-INSULIN GTT FOLLOWED PER PROTOCOL.DCD AT 0500 FOR GLUCOSE=65.\n\nI.D.-CONTINUES ON VANCO 1GM FOR 3 MORE DOSES.\n\nA/P -STALE P/O COURSE. CONTINUE TO WEAN IABP, DCD SWAN. OOB-> CHAIR.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-16 00:00:00.000", "description": "Report", "row_id": 1341263, "text": "NEURO: INTACT, OOB TO CHAIR, AMBULATED WITH HELP, TOLERATED WELL.\nCARDIAC: NSR WITHOUT. UNIT CELLS GIVEN. PACING WIRES DC'D. POTASSIUM REPLEATED WITH 40 PO K.\nRESP: CS CLEAR, DIMINISHED IN BASES. DOING SPIROCARE FAIR, C/R TAN.\nGI: POOR APPETITE BUT TRYING.\nGU: IV LASIX AFTER UNIT CELLS WITH GOOD EFFECT. URINE CLEAR.\nENDO: INSULIN GTT OFF, FOLLOWING NEW SLIDING SCALE.\nFAMILY IN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-17 00:00:00.000", "description": "Report", "row_id": 1341264, "text": "QUIET NOC. PT SLEPT IN MEDIUM LENGHT NAPS. COMPLETELY INTACT. HEMODYNAMICALLY STABLE. LS DIM AT BASES. 2LNC=95%. RA=90%. SOFT,TAKING PO LIQUIDS.PASSING FLATUS. FOLEY DCD AT 2400. VOIDING CLEAR YELLOW URINE. BLE WITH 2+ EDEMA. + PP. OOB TO COMMODE WITH 1 ASSIST. CAL/MAG REPLACED.UNCOMPLICATED P/O COURSE. TRANSFER TO 2 TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-15 00:00:00.000", "description": "Report", "row_id": 1341261, "text": "ALTERED CARDIAC STATUS\nS: \"CAN I PLEASE SIT UP NOW?\"\nO: CARDIAC: SR 80-90'S WITH ISOLATED PVC'S NOTED. SBP 110'S, CI>2.2,IABP DC'D WITHOUT INCIDENT, RIGHT FEM SITE C+D , SOFT, NO HEMATOMA NOTED.PP VIA DOPPLER, FEET EXTREMELY PT DENIED THIS BOTHERED HIM, WARM BLANKETS PLACED ON FEET AND PRESENTLY WARM, PP VIA DOPPLER, FLEETING PT PULSES. HCT 27.5. K,CA+MAG WNL THIS AM,REPEAT PENDING. DSGS D+I, .OOB @ 1630 WITH ASSIST OF 2 TOLERATED WELL.\n RESP: RR TEENS-20'S, BS DIMINISHED BIBASILAR, GOOD COUGH NOT RAISING. IS 500-600 WITH MUCH ENCOURAGEMENT. O2 SAT ON 4LNP >97%. NO CT LEAK NOTED\n NEURO: APPEARS ANXIOUS AT TIMES, PLEASANT , PERL, GRASPS STRONG AND EQUAL,MAE,PERL.\n GI: ADEQUATE UO, 20 MG LASIX @ 1645-DIURESIS PRESENTLY,\n GU: TAKING ICE WATER @ PRESENT, REFUSES PO'S. ZANTAC X1. + FLATUS, + BOWEL SOUNDS.\n ENDO: 3 UNITS SLIDING SCALE INSULIN X1, REPEAT GLUCOSE PENDING.\n PAIN: MSO4 4 MG SC X2, PERCOCET 2 TABS X1 WITH GOOD EFFECT.\n SOCIAL: FAMILY INOT VISIT AND UPDATED.\nA: TOLERATED IABP DC, DIURESISING, OOB TO CHAIR, FEET WARM AT PRESENT,\nP: MONITOR COMFORT, HR AND RTYTHYM, SBP, CI- SWAN TO BE DCD AFTER CT DCD PER DR. , CT- CT TO BE DC'D UPON RETURN TO BED, RESP STATUS- PULM TOILET, NEURO STATUS, I+O, LABS. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-16 00:00:00.000", "description": "Report", "row_id": 1341262, "text": "QUIET NOC. PT SLEPT IN SHORT NAPS. AWAKENS EASILY TO VOICE. ALET/COOPERATIVE WITH CARE. FOLLOWS COMMANDS,MAE.PERCOCET X1 FOR PAIN.\n\nCV- NSR RARE PVC. BP STABLE. SBP DECREASED TO 85/45 AFTER TAKING 25MG PO LOPRESSOR. MD NOTIFIED. DOSE DECREASED TO 12.5MG PO. CO/CI/PA/CVP ALL WNL. SWAN DCD.\n\nRESP- 4LNC->2LNC. SATS=98%. BILATERAL BASES DIM. USING IS (UP TO 600) WITH MUCH ENCOURAGEMENT. NON=PRODUCTIVE COUGH.\n\nG.I- SOFT +BS. TOLERATED PO LIQUIDS. SWALLOWS MEDS WITHOUT DIFFICULTY.\n\nG.U.-URINE INITIALLY CLEAR THEN BECOMING SLIGHTLY CLOUDY AND CONCENTRATED. 20MG IVP LASIX GIVEN A/O.\n\nLABS/ENDO-K+/CAL REPLACED.CONTINUES ON VANCO & LEVO IV.\n\nPLAN- OOB TO CHAIR. AMBULATE AROUND UNIT.POSSIBLE TRANSFER TO 2\nENCOURAGE I.S. INCREASE PO INTAKE.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-11 00:00:00.000", "description": "Report", "row_id": 1341251, "text": "PT UPDATE\n NEURO: PT A&O X3. PT MORE ANXIOUS THIS SECOND. TO NOT FEELING WELL. SEEMS SL. LESS ANXIOUS NOW. GIVEN SERAX THIS AM WITH GOOD EFFECT.\n\n RESP: SATS 96-98 ON 3LNP. BS CLEAR THIS AM. SL. DECREASED IN RT BASE THIS AFTERNOON AND TEMP UP TO 100-PT GIVEN IS AND DOES WELL. WILL CONT WITH IS.\n\n CV: HR 60-70 SR. OCC PAC'S, RARE PVC. IABP BP 100-115/50-60. RADIAL ALINE INSERTED THIS AM; 110-120/50-60 BY ALINE. PT ON 8MCG/KG/MIN THIS AM NTG. WEANED DOWN SLIGHTLY TO 6 MCG; BUT PT HAS SLIGHT EPISODE OF CP (#3 / 10) AFTER STRAINING ON BEDPAN; SO NTG BACK UP TO 7; GIVEN 2MG IV MSO4 AND PAIN GONE WITHIN 5 MIN. PT REMAINS ON IABP WITH ONLY FAIR UNLOADING;IABP FLUSHED, ZEROED AND TIMING CHANGED WITH SLIGHT IMPROVEMENT. NO OTHER EPISODES OF CP.\n\n GU: PT WITH ADEQUATE U/O THIS AM; SPONTANEOUSLY DIURESING SINCE 11A.\n\n GI: PT VERY NAUSEOUS THIS AM. VOMITED SM AMT BILOUS-STARTED ON ZANTAC AND GIVEN ZOFRAN AFTER VOMITING. NO FURTHER NAUSEA/VOMITING SINCE THIS AM. REMAINS NPO. SIPS WITH MEDS.\n\n LAB: K 3.6-REPLETED WITH 20 MEQ KCL IV. BS 170-180 RANGE-PT IS NOT DIABETIC; BUT COVERED WITH SS REG. PLTS UP TO 164 THIS AM. PT SEEN BY HEMATOLOGY. PT/PTT 17.6/67.4 WHICH IS RANGE THEY WANT IT TO BE. PT CONT ON BIVALIRUDIN AT .2-NO CHANGES MADE IN DOSE TODAY.\n\n OTHER: PT HAS ; FEET WARM; TOES ONLY SLIGHTLY COOL. IABP RT FEM OOZING SM AMT SEROSANG DRG-DSG CHANGED AND D&I FOR FEW HOURS. PT'S FAMILY IN. HAS MANY FAMILY MEMBERS AND THEY ARE ALLOWING PT TO REST. PT ENCOURAGED TO TURN SIDE-SIDE. SEEMS MORE COMF THIS AFTERNOON THAN HE WAS LAST NIGHT. MED WITH TYLENOL FOR H/A. SURGERY IS NOT YET SCHEDULED.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-12 00:00:00.000", "description": "Report", "row_id": 1341252, "text": " CSRU 7P-7A SHIFT SUMMARY NURSING NOTE;\n\nNEURO; ALERT, ORIENTED, FOLLOWS COMMANDS AND MAE'S EQUAL BILATERALLY.\n\nRESP; LUNGS CLEAR TO DIM IN THE BASES. 02 SAT'S,RR AND ABG WNL ON 3L N/C. NO C/O'S OF SOB.\n\nCARDIOVAS; NSR 60-70'S NO ECTOPY. SBP WNL AND MAP >60 AND <90. NTG GTT TITRATED DOWN ACCORDING TO MAP AND NO CHEST PAIN. IABP 1:1 WITH GOOD AUGUMENTATION AND UNLOADING. RT GROIN VENOUS SHEATH AND IABP INSERTION SITE CDI NO HEMATOMA NOTED. DISTAL BILATERAL PULSES POSITIVE BY PALPATION. POTASSIUM REPLACED PER ORDERS. PT ON BIVILIRUDIN GTT AT 0.2 MG/KG/HR PER ORDERS AM PTT PENDING AT THIS TIME ALONG WITH HIT DRAWN ON .\n\nGI; BS PRESENT NO C/O NAUSEA THIS SHIFT. SM BM OF BROWN MUCUS STOOL X1\n\nGU; GOOD HOURLY URINE OP. URINE TO PINK TINGED WITH STRANDS OF BLOOD AND SOME REDDISH SEDIMENT NOTED.\n\nCOMFORT; NO C/O'S OF PAIN ALL SHIFT. SLEPT WELL OVER NOC AFTER RECIEVING SERAX 15MG PO AT HS.\n\nPLAN; CONT TO MONITOR AND ASSESS. NEEDS CABG AS SOON AS CLEARED FOR SURGERY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-14 00:00:00.000", "description": "Report", "row_id": 1341257, "text": " CSRU 7P-7A SHIFT SUMMARY;\n\nNEURO; INTACT.\n\nRESP; LUNGS CLEAR DIM IN THE BASES. RR AND 02 SAT'S WNL ON R/A X 2HRS AND R/A BASELINE ABG WNL. PT REST OF NOC ON 2L N/C. DENIES ANY C/O'S SOB.\n\nCARDIOVAS; SB 55-SR 60'S. NO ECTOPY EXCEPT DID HAVE 11 BEAT RUN VTACH AT APPROX. 2240 WHILE BEING BATHED. PT WAS ASYMPTOMATIC AT THAT TIME. PT GIVEN 2 GMS MG SULFATE IVPB. DR AND IN TO SEE PT. EKG DONE\nLYTES CHECK AND PT GIVEN 20 MEQ KCL IVPB X1. HEPARIN 800U RUNNING PER ORDERS AND TO BE CONT TO OR THIS AM. NTG DRIP MAINTAINED AND TITRATED TO BP. NO C/O'S CHEST PAIN ALL SHIFT. IABP 1:1 WITH GOOD AUGMENTATION AND UNLOADING.\n\nGI; NO C/O'S NAUSEA. BEGINNING OF SHIFT C/O OF GAS PAINS AND COULD FEEL IT RUMBLING IN HIS ABD. STATED GAS PAINS AT TIME VERY SHARP AND PAINFUL PT STATED HE WAS MISERABLE. ALSO, STATES HE GOT MOM EARLIER WITH NO EFFECT. PT GIVEN SUPPOS. WITH NO BM NOTED BUT STATES FELT BETTER AFTER GETTING ON THE BEDPAN X2 AND PASSED LARGE AMTS OF FLATUS. ABD SOFT DISTENTED BS HYPERACTIVE AND ABD NONTENDER TO PALPATION. NPO FOR OR THIS AM.\n\nGU; URINE OP WNL UNTIL EARLY THIS AM. DR IN THE UNIT AND NOTIFIED. C-RAY DONE FOR IABP PLACEMENT AND CT TEAM STATES IABP PLACEMENT OK.\n\nCOMFORT; BEGINNING OF SHIFT PT WITH OF BACK DISCOMFORT. PT GIVEN PERCOCET 2 TABS AND MSO4 2MG X2 WITH EXCELLENT EFFECT.\n\nPLAN; CABG THIS AM\n" }, { "category": "Nursing/other", "chartdate": "2200-02-14 00:00:00.000", "description": "Report", "row_id": 1341258, "text": "POST OP\nNEURO ARRIVED FROM OR PROPOFOL 20MCGS UNRESPONSIVE SHIVERING TX WITH DEMERAL WITH LITTLE EFFECT PROPOFOL INCREASE TO PREVENT INCREASE SHIVERING FROM WAKING MAINTAINED AT 30MCGS EYES OPEN WHEN SUCTIONED REVERSED 1730 WEANING PROPOFOL\n\nRESP ABG PAO2 190S ON 100% PEEP INCREASE TO 7.5 WITH IMPROVED ABG PAO2 390 LUNGS CLEAR SUCTIONED FOR SMALL YELLOW SECRETIONS WEANING VENT O2 DECREASE 50% SATS 100% RR 18 VOLUMES 700 CHEST TUBES PATENT DRAINING MOD AMTS SANG TURN SIDE TO SIDE WITH ONLY 30CC OUT\n\nC/V ARRIVED FROM OR APACED 88 HR INCREASE TO 94 SR PACER A WIRES ONLY TURNED DOWN TO BACK UP RATE 68 AWIRES SENSING AND CAPTURING APPROPRIATLY GOOD PEDAL PULSES SR WITH INCREASING PVC COUPLET X1 LABS NOT READY 2GMS MAG GIVEN PER PA WITH RESOLUTION OF ECT NO FURTHER PVCS KCL 40MEQ GIVEN B/P MARGINAL AT TIMES WITH CVP 18 PAD 22 500CC LR GIVEN NEO STARTED .3MCG WITH GOOD EFFECT BS INSULIN 2 UNITS BOLUS GIVEN WITH 2 UNITS HOUR STARTED PER PROTOCOL CO/CI WNL\n\nGU/GI LARGE URINE OUT 300-500 HOUR MD SOFT MOD LIQUID STOOL X1 SOFT PA NOTIFIED PT RECIEVED SUPPOSITORIES AND MOM PRE OP WITH NO RESULTS\n\nPLAN CONTINUE TO MONITOR NEED TO REPLACE LARGE URINE OUT CONTINUE TO WEAN PROPOFOL AND VENT AS TOLERATED\n" }, { "category": "Nursing/other", "chartdate": "2200-02-10 00:00:00.000", "description": "Report", "row_id": 1341248, "text": "ADMISSION NOTE\n74 Y/O PMH SPINAL CYST SX SEVERAL YRS AGO HTN DEVELOPED CP LAST NOC RELIEVED ON OWN WENT TO BED AWOKE THIS AM WITH RETURN OF CP AND PRESSURE WITH RADIATION TO L ARM TO ER R/I MI CONTINUE PAIN TO CATH LAB AT HOSPITAL 3 VESSEL DISEASE IABP INSERTED FOR CONTINUED PAIN AT HOSPITAL AND TX TO BIDH FOR EVAL FOR CABG\n\nNEURO ALERT ORIENTED NO DEFECITS NOTED\n\nRESP NC 2L SATS 98% LUNGS CLEAR DENIES SOB\n\nC/V SB NO ECT B/P STABLE ON INCREASING NTG FOR PERSISTANT PAIN/PRESSURE AT #3 DOWN FROM PREVIOUS #7 HEPARIN INFUSING 1000U HOUR GOOD PEDAL PULSES IABP IN PLACE WITH AUGMENTATION\n\nPLAN RELIEVE PAIN EVALUATE CARDIAC STATUS ? OR TODAY FOR CABG\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-10 00:00:00.000", "description": "Report", "row_id": 1341249, "text": "NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nRESP NC INCREASE 3L SATS 98% LUNGS CLEAR\n\nC/V IABP PATENT CONTINUE ON TOL WELL NTG INCREASE TO 5.5MCG MS 2MG IV GIVEN FOR #3 CHEST PRESSURE WITH ONLY SLIGHT LESS THAN #1 CHEST PRESSURE REMAINING MIDCHEST SIZE OF THUMB PT STATES NTG MAINTAINED TO B/P >110 SYST HEPARIN INCREASE 1100U HOUR FOR PTT 58\n\nPLAN CONTINUE TO MONITOR PAIN/PRESSURE MAINTAIN HEMODYNAMICS FOR CABG IN AM\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-11 00:00:00.000", "description": "Report", "row_id": 1341250, "text": "NPN:\n\nNEURO: ALERT AND ORIENTED X3, MAE. CALM AND COOPERATIVE BUT APPROPRIATELY ANXIOUS AT TIMES. BENADRYL GIVEN FOR SLEEP WITH LITTLE EFFECT.\n\nCV: 55-70 SR WITH RARE APC NOTED. ON IV NTG TITRATED TO KEEP PT PAIN FREE AND WITH SBP<120. IABP IN R FEM WITH GOOD AUGMENTATION AND UNLOADING. PALP PEDAL PULSES WITH CAP REFILL <3. IABP SITE CONT WITH SM OOZING OF BLOOD-DR CHANGED X2. PT ON HEPARIN GTT NOTED TO HAVE DECREASED PLTS TO 78..PT SEEN BY DR AND RECOMMENDED STOPPING HEPARIN AND PT STARTED ON BIVALIRUDIN. PT WITH N/V X2 AND MULTIPLE C/O GASSY TYPE L SIDED PRESSURE UNDER RIB CAGE.? ANGINA--EKG TAKEN--PT TREATED WITH MSO4 WITH SOME RELIEF BUT NOT COMPLETE RESOLUTION. CK'S SENT AT 0040AM AND LAB LOST..REPEATED AT 230 WITH CK 1241 WITH MB 97. HCT 34.2. COAGS WITH ELEVATED PT >20 AND INR 2.8, PTT 66-DR AWARE-- ON BIVAL. BLOOD SENT TO BB FOR HIT W/U. PLTS THIS AM 161.\n\nRESP: LUNGS CTA BIL. O2 SATS> 95% ON 3L NC O2.\n\nGU: FOLEY TO GD WITH UO 23-80CC/HR. CR STABLE.\n\nGI: ABD SOFT, NT, ND WITH C/O L SIDED PAIN UNDER RIB CAGE-?. NAUSEA AND VOMITTING-TREATED WITH ZOFRAN 2MG IV X3. +BELCHING AND C/O GASSY TYPE PRESSURE INTERMITTENTLY DURING THE NIGHT.\n\nENDO: GLUCOSES 117-191..CONT TO OBSERVE -NO TREATMENT.\n\nID: TMAX 99.6 THIS AM AT 4 WITH WBC ELEVATED 15\n\nACTIVITY: ON BEDREST WITH R LEG STRAIGHT R/T IABP--RESTLESS AND UNCOMFORTABLE AT TIMES. TURNED SLIGHTLY SIDE TO SIDE- R SIDE AS TOL.\n\nCOMFORT: MEDICATED WITH MSO4 2MG IV FOR L SIDED PRESSURE/GASSY PAIN WITH SOME RELEIF.\n\nA: PT CONT WITH ELEVATED CK'S-CONT INFARCTION\n DECREASED PLTS ON HEPARIN-IMPROVED -W/U HIT\n\nP: CONT TO CONTROL CP, N/V AND BP WITH IABP, NTG AND MSO4, BIVALIRUDIN AS ORDERED FOR ANTICOAG--ASSESS NEED FOR ADJUSTMENT. CONT TO FOLLOW CK'S AND MB. HIT --? HEME CONSULT ALTHOUGH PLTS IMPROVED. AWAIT OR PLAN PER DR IN CONSULTATION WITH CARDIOLOGY.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-12 00:00:00.000", "description": "Report", "row_id": 1341253, "text": "Pt awake alert oriented awaitng surgery plan for friday pending HIT panel pt teaching done r/t postop CABG pt receptive and asking questions Pt free of CP/pressure c/o back pain tylenol with relief\n\nNeuro- MAEW intact verbalize needs\nCV-VSS MP SR with inverT wave and qwave on 12 lead EKG NTG gtt cont at .40mcg/kg/min cont agiomax at .2mg/min PTT WNL goal 60-80 IABP 1:1 augmenting and unloading right fem site CDI no hematoma pt aware to notify nurse of any CP/pressure cont to monitor and cont preop teaching\nResp-O2 3l N/P sao2 98-100 LS fine crackles right base clear upper lobes using ICS 1000 CDB cont pulm toilet\nGI-taking in PO full liq BS WNL zantac PO\nGU-foley-CD pink urine will ck HCT later u/o>80cc/hr K ck and wnl\nSkin intact\nPlease see flow sheet/cont current care\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-13 00:00:00.000", "description": "Report", "row_id": 1341254, "text": "3/112 CSRU 7P-7A SHIFT SUMMARY NOTE;\n\nNEURO; INTACT, SLEPT WELL AFTER SERAX 15MG PO AT HS.\n\nRESP; LUNGS CLEAR DIM IN THE BASES NO C/O'S SOB. 02 SAT'S WNL ON N/C.\n\nCARDIOVAS; SB 56-SR 60'S NO ECTOPY. IV NTG TITRATED TO BP AND CONTINUES OVER NOC AT 0.25 MCG/KG/MIN. PT DENIES ANY C-PAIN. BIVILIRUDIN CONT'S AT 0.2MG/KG/MIN. WITH PTT DRAWN Q6HRS AND REMAINS THERAPUTIC. IABP 1:1 WITH GOOD TRACE AND UNLOADING. RT. FEM. IABP AND VENOUS SHEATH INSERTION SITE CDI WITH NO HEMATOMA NOTED. DISTAL PULSES EASILY PALPABLE WITH GOOD CSM DISTAL BILATERALLY.\n\nGI; BS PRESENT NO BM THIS SHIFT. TAKING AND TOL. FLUIDS WITH NO C/O'S NAUSEA.\n\nGU; HOURLY URINE OP WNL. URINE YELLOW TONIGHT WITH SOME PINK SEDIMENT.\n\nENDO; BLD SUGARS BEING FOLLOW BY SS. PT GIVEN 3U REG SQ OVER NOC.\n\nCOMFORT; PT DID C/O SLIGHT HA AND GIVEN TYLENOL 650MG PO WITH GOOD EFFECT.\n\nPLAN; CONT. TO MONITOR AND ASSESS. CONT. AND REINFORCE PRE- OP TEACHING TODAY. SURGERY FRIDAY.\n" }, { "category": "Nursing/other", "chartdate": "2200-02-13 00:00:00.000", "description": "Report", "row_id": 1341255, "text": " 0430 NOTE ADDEM:\n\nCOMFORT; PT C/O RT SIDED LOWER BACK DISCOMFORT. PT GIVEN MS04 2MG IVP X2 WITH NO EFFECT. PT GIVEN PERCOCET 1 TAB PO AND AWAITING FOR EFFECT. RT GROIN NO HEMATOMA NOTED HCT WNL. SBP ALSO WNL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-02-13 00:00:00.000", "description": "Report", "row_id": 1341256, "text": "PT UPDATE\n : PT A&O X3. FAIRLY CALM.\n\n RESP: BS CLEAR, SL. DECREASED IN BASES. ENCOURAGED TO USE IS-DOES WELL. NON-PRODUCTIVE COUGH. SATS 96-98 ON 3LNP. RR MID TEENS.\n\n CV: PT WITH HR 70'S SR. BP 120-130. PT REMAINS ON IABP 1:1 WITH ONLY FAIR UNLOADING. TIMING MANIPULATED WITH FAIR RESPONSE. PT REMAINS ON .25MCG NTG WITH NO C/O CP.\n\n GU: ADEQUATE U/O.\n\n GI: PT TAKING SOLIDS W/O DIFFICULTY. HAS BS; BUT NO FURTHER BM TODAY. ONLY FAIR APPETITE.\n\n LAB: BS COVERED WITH SS INSULIN-130 RANGE.\n\n OTHER: NO BLDING AT IABP SITE. PT WAS VERY UNCOMF. THIS AM WITH BACK PAIN. MED WITH PERCOCET EARLY AM WITH GOOD RELIEF; AND NO C/O SINCE THIS AM. PRE-OP TEACHING CONT WITH PT AND FAMILY. PT FOR OR AM.\n" }, { "category": "ECG", "chartdate": "2200-02-14 00:00:00.000", "description": "Report", "row_id": 169387, "text": "Normal sinus rhythm. Low QRS voltage in the limb leads. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of the\nheart rate is now slower. Otherwise, multiple abnormalities persist without\ndiagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2200-02-10 00:00:00.000", "description": "Report", "row_id": 169388, "text": "Sinus bradycardia\nST-T wave changes with slight lateral ST elevation - cannot exclude\ninjury/ischemia - clinical correlation is suggested\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2133-09-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1201421, "text": " 12:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with s/p ccy\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation after placement of a central line.\n\n COMPARISON: .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: A right-sided IJ line is seen ending in the mid-to-lower SVC.\n Otherwise there are good lung volumes without focal radiopacities concerning\n for pneumonia but with mild vascular engorgement probably due to some fluid\n overload. Cardiomediastinal and hilar contours are unremarkable. Moderate\n cardiomegaly is present and stable since prior exam on . No\n pneumothorax is seen. A pacemaker is observed with three leads ending in\n standard position in the right atrium, right ventricle and left ventricle.\n\n IMPRESSION: No acute cardiopulmonary disease. Stable moderate cardiomegaly,\n mild pulmonary vascular congestion.\n\n" }, { "category": "Echo", "chartdate": "2133-09-03 00:00:00.000", "description": "Report", "row_id": 64564, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative laparascopic cholecystectomy with previous history of ICU admission with sepsis and high dose inotropic requirement in the recent past\nStatus: Inpatient\nDate/Time: at 15:24\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Severe regional LV systolic\ndysfunction. Severely depressed LVEF.\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. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Normal descending 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. Mild to moderate (+)\nMR.\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 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:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. The right atrium is dilated. No atrial septal\ndefect is seen by 2D or color Doppler.\n\nThe left ventricular cavity is moderately dilated. There is severe regional\nleft ventricular systolic dysfunction with with somewhat preserved function in\nthe basal lateral, inferior and anterior walls. Overall left ventricular\nsystolic function is severely depressed (LVEF= 15%).\n\nRight ventricular chamber size and free wall motion are normal. There are\nsimple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\nDrs. and was notified in person of the results before surgical\nincision.\nImpression:\nNormal RV systolic function.\nSeveral LV systolic dysfunction.\n.\n\n\n" }, { "category": "ECG", "chartdate": "2133-09-03 00:00:00.000", "description": "Report", "row_id": 131909, "text": "Sinus rhythm with ventricular pacing and fusion beats. Single ventricular\npremature beat. Compared to the previous tracing of ventricular ectopy\nand fusions beats are new. The QRS morphology of the paced complexes is\nunchanged.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2133-09-04 00:00:00.000", "description": "Report", "row_id": 131907, "text": "Atrial sensed, ventricular paced rhythm with relatively short interval.\nCompared to the previous tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2133-09-04 00:00:00.000", "description": "Report", "row_id": 131908, "text": "Sinus rhythm with ventricular pacing. Compared to the previous tracing\nof ventricular ectopy and fusion complexes are absent. Morphology of\npaced QRS complexes is unchanged.\nTRACNIG #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2121-03-21 00:00:00.000", "description": "Report", "row_id": 100569, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 140\nBSA (m2): 1.78 m2\nBP (mm Hg): 115/65\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 13:05\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 normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\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\nAORTA: The aortic root is mildly dilated.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmild aortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The left ventricular inflow pattern suggests\nimpaired relaxation.\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\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated. The\naortic valve leaflets are moderately thickened. There is mild aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The left ventricular inflow pattern suggests impaired\nrelaxation. There is no pericardial effusion.\n\nIMPRESSION: No vegetation seen (cannot definitively exclude).\n\n\n" }, { "category": "ECG", "chartdate": "2121-03-22 00:00:00.000", "description": "Report", "row_id": 294015, "text": "Sinus rhythm and atrial bigeminy. Left atrial abnormality. ST-T wave flattening\nin leads I and aVL. Right bundle-branch block. Compared to the previous tracing\nof atrial bigeminy has appeared.\n\n" }, { "category": "ECG", "chartdate": "2121-03-20 00:00:00.000", "description": "Report", "row_id": 294016, "text": "Sinus rhythm with borderline resting sinus tachycardia. Baseline artifact. Left\natrial abnormality. Complete right bundle-branch block. Non-specific ST-T wave\nchanges in lead aVL. ST segments cannot be reliably assessed in the lateral\nprecordial leads because of baseline movement. Compared to the previous tracing\nof no apparent diagnostic change. Repeat tracing suggested if clinically\nindicated.\n\n" }, { "category": "ECG", "chartdate": "2121-03-19 00:00:00.000", "description": "Report", "row_id": 294017, "text": "Sinus rhythm\nConsider left atrial abnormality\nRight bundle branch block\nSince previous tracing of , precordial T wave less prominent\n\n" }, { "category": "ECG", "chartdate": "2121-03-18 00:00:00.000", "description": "Report", "row_id": 294018, "text": "Sinus rhythm. Right bundle-branch block. Left atrial abnormality. Tall peaked\nprecordial T waves. Compared to the previous tracing of the rate has\nincreased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-20 00:00:00.000", "description": "Report", "row_id": 1276883, "text": "NSG TRANSFER NOTE ACCEPTANCE NOTE MICU-B\n72YO male transfered from cc7, obtunded from sedation for ETOH withdrawl, in acute respir distress with ? of aspiration PNX, that has R/I for MI and lower GI bleed.\n\nRespir: Arrived obtunded on 100% NRB, with O2 sats 99-100%, RR 40's in mild distress, L/S diminshed bilat. Last ABG before intubation 110/57/7.28/0. Was intubated on placed A/C 100/600/14 peep-5, with repeat ABG- 7.40/36/344/23/-1, FIO2 decreased to 60%. Several attempts to place an A-line made but with no success. CXR in AM was clear. Repeat CXR s/p intubation. Suctioned q2hr for lrge amts thick yellow sputum.\n\nNeuro: Has hx of ETOH abuse and was + for Cocaine upon admission, was very combative in EU, required 4pts restraints was sedated and sent to cc7 on , remained obtunded but still rec'd Ativan 4mg q4hr even though was unresponsive. Upon admit to MICU was unresponsive to sternal rub and no spon movements noted. PERL,3mm. S/P intubation was started on Versed Gtt 2mg/hr. Does occ respond to painful stimuli(ie A-line placement). Has + cough and gag, and + corneals. Head CT was neg. Unable to follow the CIWA scale here.\n\nID: Temp 101.5 PO with WBC 29.5, one set on BC's were sent from cc7 and one set to be sent from MICU. Sputum was obtained and sent for C&S. Started on IV Clinda and Levofloxcin. Urine had been sent on floor.\n\nC/V: Had R/I for MI on upon admit, with high CPK's and troponin levels. BP 100-128/60, HR 85-95ST with no ectopy noted. K+-4.3.\n\nGU: U/O since transfer 40-50cc/hr, BUN/CRE-47/1.0, with Na+150, was placed on 1/2NS @ 125cc/hr. Repeat labs to be drawn this evening.\n\nGI: OGT placed, remains NPO no stool noted since transfer. Last HCT-33.7. Rec'd a total of 2units PC's on the floor for lower GI bleed was having black tarry stools on the floor, with admit HCT- 25.2.\n\nA/P: Continue with aggressive Pulmonary toilet, assess O2sats and ABG's adjust vent settings as needed. Keep sedated, and follow the CIWA scale when awake. Monitor temps and administer IV antibx's check BC's results. Monitor VS and I&O's and check lytes frequ.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-21 00:00:00.000", "description": "Report", "row_id": 1276884, "text": "Nursing Process Note: 1900-0700\nNEURO: Received patient adequately sedated on Versed gtt @ 2mg/hr. Moving extremities at times; soft wrist restraints applied to maintain integrity of lines. Reponsive to nailbed pressure. Pupils 3mm/brisk bilat.\n\nRESP: A/C 600X14/5/FiO2 40%. Overbreathing vent few breaths up to RR 20. LS clr/diminished at bases. Sats consistently mid-high 90s. Last ABG: 7.43/31/79. Sx for small amt thick, wht sputum. Gag/cough intact.\n\nC/V: BPs 100-110s/50-60s. HR 80s, no ectopy. Receiving maintenance fluid .45% NS @ 125/hr. Received .45% NS 500cc bolus for decreased urine output.\n\nGI/GU: NPO. OGT placement confirmed by CXR; able to receive PO meds. Gastric aspirate slightly OB positive. Abd soft, active sounds. No stool this shift. Foley patent for amber urine, output ~ 30cc/hr.\n\nID: Remains febrile; tmax 102.1 PO. Bld cx previously done and pnd. Gave tylenol via OGT with minimal effect. AM labs pnd.\n\nSOCIAL: Unknown if any family.\n\nPLAN: Monitor labs; plan to keep hct >=30.\n Monitor temp.\n Stool for cdiff when available.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-24 00:00:00.000", "description": "Report", "row_id": 1276896, "text": "Resp; pt on psv 5/5/40%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned for moderate-copious thick yellow secretions. MDI's administered Q4 with no adverse reactions. Pt awake, not following commands. Pt returned to a/c noc for ^ in rr, bp, hr. RSBI=65. Returne o psv this am. Plan to possible extubate today.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-24 00:00:00.000", "description": "Report", "row_id": 1276897, "text": "Patient extubated and placed on 40% open face mask,HR 85,RR 24,Sat 97%. Patient talkative,coughing and expectorating. BS diminished will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-24 00:00:00.000", "description": "Report", "row_id": 1276898, "text": "NEURO: Alert and oriented to person only. Pt successfully extubated this am. +MAE noted. Pt has weak/hoarse voice and occasionally follows simple commands. Cough/gag intact. Bed alarm on(found with BLE over SR but no attempts to get OOB) + bilat swoft hand restraints d/c'd.\nCV: Monitor shows NSR with no ectopy noted.\nRESP: LS coarse throughout. +prod cough thick white secretions. Pt on 40% humidified cool mist. No sob or resp distress noted.\nGI: Abd soft and nontender. +BS noted FIB with lg leakage and mushroom catheter inserted...draining liquid brown stool. Held all po meds high risk for aspiration and difficulty swallowing noted.\nGU: Foley intact and patent draining yellow urine without sedimentation noted.\nHEME: Hct to be checked this eve.\nI-D: Afebrile. Remains off abx and bld cx's pending.\nPSY-SOC: No phonecalls or vistiors this shift. ? c/o to floor in am.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-25 00:00:00.000", "description": "Report", "row_id": 1276899, "text": "MICU-NPN\n\nNEURO: Pt. A&O to person only. Unable to reorient. MAE. CIWA scale Q1hr. Received 1mg ativan for CIWA >11. Has periods of increasing agitation, swearing, trying to climb OOB. Bilat. wrist restraints applied. Siderails up/bed alarm on. Pt. found to have legs over side rail trying to get OOB (Pt. stated that he \"Needs to go to the store\"). Posey applied for pt. safety.\nCV: afebrile, HR 60's-70's NSR, no ectopy noted. SBP 118-150's.\nRESP: LS coarse, diminished @ bases. Scoop mask .45 cool mist. Sat's 97-99%. RR 16-29. Productive cough for thick, yellow sputum.\nGI: Abdomen soft and non-distended, +BS, Mushroom cath intact drng liquid brown stool. All PO meds held d/t pt's high risk for aspiration. MD aware. D51/2NS @75cc/hr started.\nGU: Foley drng. adeq. amt's of clear, yellow urine. 30-190cc/hr.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-25 00:00:00.000", "description": "Report", "row_id": 1276900, "text": "RESPIRATORY CARE:\n\nFollowing for prn neb rx's. Pt did well overnoc. Strong cough, clearing secretions well. Pt . Will continue to follow prn. Please reassess for bronchodilator tx.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-23 00:00:00.000", "description": "Report", "row_id": 1276892, "text": "\nPt maintained on psv ventilation at 40% with good oxygenation and stable vitals. Pt is awake with clear B.S. and little in the way of secretions. Clinically with the exception of some intermittent guiac positive stools pt is ready for extubation. Morning rounds took the direction of waiting until tomorrow a.m. for that to occur. Plan is to bump up psv ventilation overnight, return to by six in preparation for extubation.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-23 00:00:00.000", "description": "Report", "row_id": 1276893, "text": "NPN MICU-B 7AM-7PM\nS/O: NEURO: Increased alertness noted opening eyes spon and to voice, able to turn head to voice and occ obeys simple commands ie hand grasps. Moving all extremities spon and being restless rec'd Olanzapine 2.5mg PO times 2, with good response.\n\nC/V: BP-140-170's/70, HR 73-80 SR with occ PVC's. Was started on Loprssor 25mg PO bid, with good response BP down to 130-140/70, HR 60's SR no ectopy. K+-4.0.\n\nGI: Still having lrge amts liquidy brown OB+ diarrhea has had over 800cc so far today. Has FIB in place working well. Remains NPO, abod soft non-tender with +BS's. HCT stable @ 31.1 repeat HCT to be checked this evening. Lactulose was d/c'd.\n\nGU: U/O 40-60cchr, IVF decreased to D51/2 @60cc/hr.\n\nRespir: Remains intubated but able to change from A/C to PSV-5, Peep-5 FIO2-40%. O2 sats 95-99%, L/S clear. Suctioning q3-4hr for thick light yellow sputum.\n\nID: Temps 100.3 PO max, rec'd Tylenol 650mg,PO times one. Temp down to 97.8 PO, remains off of antibx's.\n\nA/P: Continue to monitor Neuro status, provide for pt's safety. Assess I&O's, check lytes replete if needed. Monitor temps and reculture if needed. Assess VS.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-24 00:00:00.000", "description": "Report", "row_id": 1276894, "text": "Nursing Process Note: 1900-0700\n72 yo man admitted with GIB. Very combative in EW. PMH significant for ETOH, cirrohis, hepatitis. Initially sent to floor. Found unresponsive and subsequently sent to MICU; intubated for airway protection. Since here, has been spiking temps though WBC decreasing. All Abx d/c'd.\n\nNEURO: Awake. Appears to mouth words but not following commands. MAE. Opens eyes but does not track. Dozing intermittently throughout shift.\n\nRESP: Vent changed to CMV for increased HR, BP, and RR. Now 600X14/5/40%. RR in 20s. LS cta but sx for mod amt thick sputum. Sats high 90s. Still plan to extubate in AM.\n\nC/V: BP 120-140s/60s. HR in 60s, no ectopy. IVF d/c'd in attempt to balance fluid status. Hct stable at 31.\n\nID: Temp spike to 101.2 PO; bld cx X 2 sent.\n\nGI/GU: NPO. All meds via OGT. Vitamin doses changed to po. Abdomen soft, present sounds. Foley patent for yellow urine; quantities sufficient q hr.\n\nSOCIAL: Friend called previous shift stating she would notifiy patient's family of hospitalization.\n\nDISPO: Full code.\n\nPLAN: Monitor temp\n Probable extubation in AM\n" }, { "category": "Nursing/other", "chartdate": "2121-03-24 00:00:00.000", "description": "Report", "row_id": 1276895, "text": "Nursing Addendum: 0500\n0500: Agitated, biting on vent. Sx for large amt thick, yellow sputum. Gave Zyprexa 2.5 mg for agitation; awaiting results.\nHct from AM labs 32.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-22 00:00:00.000", "description": "Report", "row_id": 1276889, "text": "NPN MICU-B 7AM-7PM\nS/O: NEURO: Remains basically unresponsive, does occ respond to sternal rub with posturing of upper extremities, and does have occ spon movements of lower extremities but does not move upper extremities spon, does not open eyes spon, PERL but are just 2-3mm, no gag and impaired cough. Remains off of all sedation since yesterday. REc'ing Lactulose PO qid.\n\nREspir: Remains intubated on same vent settings no changes made due to MS, A/C 660/14/40% Peep-5. Suctioning q3hr for lrge amts thick yellow sputum, also having lrge amts oral secretions. L/S clear, to course @ bases. O2 sats 95-99%.\n\nC/V: BP 130-150/70, HR- 76-88 SR with occ PVC's, K+3.4, rec'd a total of 60mEq, 40Meq PO, 20IV, K+ to be re-checked this evening.\n\nGI: Remains NPO, had lrge amt of liquidy black stool this afternoon, HCT- 33.4. HCT to be checked q8hrs next due @ 8pm. Was lavaged but was neg. Remains on PO Lactulose. Rectal bag placed.\n\nGU: u/o 40-60cchr, BUN/CRE 29/0.8. Rec'ing D51/2NS @ 75cc/hr. Na+-143.\n\nID: Temp 100.3 PO max WBC down to 11.2, IV antibx's d/c'd.\n\nSocial: Still no word from or about any family members.\n\nIV: New #18 angio placed in Left arm.\n\nA/P: Continue to monitor Neuro status, assess for any changes, monitor I&O's, and VS's. Check lytes and replete as needed.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-23 00:00:00.000", "description": "Report", "row_id": 1276890, "text": "Resp: pt on a/c 14/600/+5/40%. Alarms on and functioning. Ambu/syringe @ hob. Bs auscultated reveal bilateral coarse sounds with diminished bases. Suctioned for small to moderate amounts of thick yellow secretions. Re-taped and secured ett. MDI's administered Q4 hrs Alb/Atr with no adverse reactions. Pt is waking up. RSBI=68. Still not following commands. Will proceed to wean to psv trial in am. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-23 00:00:00.000", "description": "Report", "row_id": 1276891, "text": "Nursing Process Note: 1900-0700\nNEURO: Patient waking up; opening eyes spontaneously, not tracking. Pupils reactive 3mm bilat. Does not follow commands. Moving all extrems except left arm and lifting head at times. Restless at times. Strong right hand grasp. No tremors noted. Bilat soft wrist restraints to maintain safety and integrity of lines.\n\nRESP: Continues on A/C 600X14/5/40%. Overbreathing up to rate of 20s. Few episodes of RR in 30s. Sats maintained high 90s to 100. Sx for mod amt thick, yellow sputum. LS clr/diminished.\n\nC/V: BPs slightly trending upward 130-150s/50-60s. HR 70-80s, SR. One episode of increased rate to 110s. Maintenance fluid D5 .45NS @ 75/hr. Diaphoretic at times but difficult to determine cause (paroxysmal sweating related to ETOH withdrawal vs fever). Hct stable 31.3; next due at noon. K 3.5-received Kcl 40 Meq PO with repeat level 4.3.\n\nID: Tmax 101.6 PO-received APAP 650mg via OGT; repeat 99 PO. WBC down to 8.7.\n\nGI/GU: NPO. OGT in place patent for PO meds. Abdomen soft, active sounds. FIB active for brn, liquid stool. Foley patent for amber urine. Output variable but >30cc/hr.\n\nDISPO: Full code.\n\nPLAN: Serial hct, next at noon.\n Monitor mental status and s&s of withdrawal.\n Questionable extubation today.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-21 00:00:00.000", "description": "Report", "row_id": 1276885, "text": "MICUB 0700-1900 RN Note\n\nNEURO: STARTED SHIFT SEDATED ON VERSED 2MG/HR, eyes closed minimal response to painful stimulation grimaces with suctioning. Pupils 2-3mm equal react brisk. Weaned sedation to off by 1030,CIWA scale initiated Range 9-4. patient remained calm and somulent/with increased responsiveness to stimulation eyes remain closed, turns head to voice and MAE on bed. no tremors or suiezure activity.\n\nCV: HR NSR rare PAC, Echo @ bedside today result pending...., SBP 110-132 MAPS 70's. Heart sounds S1 S2 + Sysolic Murmur. IV peripheral access, 0.45% NS @ 125cc/hr changed to D5W 100cc/hr. K+3.5 repleted with KCL 40meq. Hypernatremic Na+ 150.\n\nHeme: Hct 26.7 recieved 2UPRBC Hct Post 1st unig Hct 29p plan serial Hct q8hr.\n\nResp: Intubated Orally #8.0 ETT 22 R lip, Vent A/C % 5 peep, no vent changes ABG 7.43-31-79 RSBI 120 plan to lighten sedation and trial PS. Sat 96-99% Lungs caorse to clear BS. Suctioned via ETT for mod amt thick tan. Oraaly for mod amt tan .\n\nID: T-max 102.4 tylenol 650mg. cont on Abx cult pending. WBC 26.7 trending down.\n\nGI; abd soft nontender +BS no BM C-Diff to be obtained. sump orally placed clamped for meds.\n\nGU: Foley amber urine 40-120cc/hr. Creat 1.2\n\nSocial: Full code status. No family contact.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-21 00:00:00.000", "description": "Report", "row_id": 1276886, "text": "Resp care note\nPt remains on full vent support. No recent ABG's as of yet. No vent changes made today. Coarse BS, sx mod thick yellow secretions.\n" }, { "category": "Nursing/other", "chartdate": "2121-03-22 00:00:00.000", "description": "Report", "row_id": 1276887, "text": "Nursing Process Note: 1900-0700\nNEURO: Remains responsive to tactile/painful stim only though off all sedation. Not opening eyes spontaneously; pupils 3mm/brisk bilat. MAE. Started Lactulose this shift via OGT.\n\nRESP: Remains on AC 600X14/5/40%. Overbreathing few breaths. LS coarse. Sats remain in high 90s to 100. Sx for small-mod amt blood tinged sputum (s/p endoscopy today) previous shift.\n\nC/V: SBPs 120-130s/40-60s. HR SR, irregular at times 60-70s. Maintenance fluid D5W at 100/hr. Q8 hr hcts. Last at 0300 pnd.\n\nID: Tmax this shift 101.4 PO. Receiving IV Clindamycin. Bld cx from 3.4 pnd.\n\nGI/GU: OGT in place, confirmed by CXR. Patent for PO meds. Abd soft, active sounds. No results from Lactulose. Foley patent for amber urine, ~ 30-40cc/hr.\n\nSOCIAL: Questionable if any family.\n\nDISPO: Full code.\n\nPLAN: Q8 hr hct.\n Monitor temp\n Monitor mental status, lactulose a/o\n\n" }, { "category": "Nursing/other", "chartdate": "2121-03-22 00:00:00.000", "description": "Report", "row_id": 1276888, "text": "\nPT MAINTAINED ON A/C VENTILATION AT 40% WITH GOOD OXYGENATION. VITALS STABLE AND AFEBRILE. PT RESPONDS BUT IS NOT AWAKE. SX FOR SM. AMTS. PLAN IS TO STOP SEDATION, ALLOW PT TO GAIN A CLEARER MENTAL STATE AND THEN START WEANING. QUESTION AS TO WETHER THERE IS FAMILY.\n" } ]

[ { "category": "ECG", "chartdate": "2188-06-05 00:00:00.000", "description": "Report", "row_id": 133568, "text": "Unstable baseline makes interpretation difficult. The rhythm is probably sinus\ntachycardia at a rate of 106 with atrial premature beats but atrial\nfibrillation cannot be excluded. Right bundle-branch block. Inferior wall\nmyocardial infarction of indeterminate age. Compared to the previous tracing\nof atrial ectopy is new.\n\n" }, { "category": "ECG", "chartdate": "2188-06-02 00:00:00.000", "description": "Report", "row_id": 133569, "text": "Sinus tachycardia. Right bundle-branch block. Modest inferior ST-T wave\nchanges. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2188-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086189, "text": " 6:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? CT process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SOB, h/o of COPD, crackles on exam\n REASON FOR THIS EXAMINATION:\n infiltrate? CT process?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, COPD, and crackles on physical exam.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: A single frontal radiograph of the chest reveals an enlarged\n cardiac silhouette. Mediastinal and hilar contours are unremarkable. Note is\n made of vascular calcification of the aorta. Multiple surgical clips are also\n visualized along the right paratracheal stripe. The lungs are notable for\n consolidative opacity at the left lung base in the retrocardiac area as well\n as opacities at the left upper lung. A more linear area of opacity at the\n right mid lung may represent some atelectasis. Visualized osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION: Opacities at the left lung base, left upper lung, and right mid\n lung as above, these are nonspecific. Multifocal pneumonia is primarily\n considered. In addition, note is made of cardiomegaly and sequelae of thoracic\n surgery.\n\n" }, { "category": "Radiology", "chartdate": "2188-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086547, "text": " 1:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: changes from previous cxr\n Admitting Diagnosis: CHF/PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SOB, altered mental status, hypoxia\n REASON FOR THIS EXAMINATION:\n changes from previous cxr\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Hypoxia.\n\n FINDINGS: Improving opacities within the left upper and right mid lungs but\n possible slight worsening at the left lung base. These findings may be\n related to multifocal pneumonia. Post-operative changes are again\n demonstrated in the right hemithorax, likely related to previous right upper\n lobe resection and possible radiation therapy. Asymmetric right apical\n thickening may reflect post-treatment change, but comparison to older post-\n operative radiographs would be helpful to exclude recurrence. Similarly, it\n would be helpful to compare the post-operative appearance of the right hilum\n with older studies. If unavailable, consider CT after the acute parenchymal\n process resolves.\n\n IMPRESSION: Multifocal pneumonia.\n Postoperative appearance in right lung should be compared to priors to ensure\n stability as detailed above.\n\n" }, { "category": "Radiology", "chartdate": "2188-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086212, "text": " 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? progression of pneumonia versus volume overload\n Admitting Diagnosis: CHF/PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with COPD, lung cancer s/p lobectomy, here with likely\n pneumonia. Assess for interval change.\n REASON FOR THIS EXAMINATION:\n ? progression of pneumonia versus volume overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and lung cancer status post lobectomy with possible pneumonia.\n\n FINDINGS: In comparison with the earlier study of this date, there is again\n an area of increased opacification in the left base, right mid lung, and left\n upper lung, suggestive of the clinical impression of multifocal pneumonia.\n Post-surgical changes are again seen in the right apical region.\n\n\n" }, { "category": "Physician ", "chartdate": "2188-06-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 582902, "text": "Chief Complaint: Shortness of breath\n HPI:\n Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She was not experiencing any fevers. She was given increased nebulizer\n treatments with some relief. She was not experiencing chest pain or\n pleuritic type pain. She was not experiencing nausea, vomiting,\n abdominal pain, constipation, dysuria, hematuria, leg pain or\n swelling. She does endorse some mild diarrhea. She says that her\n breathing has been getting progressively worse over the past three days\n despite increasing nebulizer and oxygen therapy (titrated to 4L). She\n appeared progressively worse and EMS was called for transport to\n . When EMS arrived she was complaining of shortness of breath.\n Initial oxygen saturations were in the low 80s and these improved to\n 94% on a non-rebreather. She was noted to have scant wheezes in her\n upper lung fields. EKG showed sinus tachycardia, right bundle branch\n block, q waves in III, avF, TWF V1-V3. She was taken to the emergency\n room.\n In the ED, initial vs were: T: 98.8 P: 113 BP: 130/84 R: 25 O2 sat: 85%\n on RA. Initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block, TWI\n V1-V3, q waves III, avF, no change compared to prior earlier in the\n day. She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1,\n combivent nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on\n BIPAP with mild improvement. She also received nitroglycerine for\n potential volume overload as well as lasix 20 mg IV x 1. Her BNP was\n elevated at 1122. Her WBC was 15.1 with 91% neutrophils. She had one\n set of negative cardiac enzymes. She was admitted to the intensive\n care unit for further management.\n On arrival to the ICU she reports that her shortness of breath has\n improved somewhat from this morning. She denies fevers, chills, chest\n pain, nausea, vomiting, abdominal pain, constipation, dysuria,\n hematuria, leg pain or swelling. Comes from rehab. Has had recent\n rhinorrhea and productive cough without fevers. Mild diarrhea at\n rehab. All other review of systems negative in detail.\n Patient admitted from: ER\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 Medications:\n Bactrim DS (started )\n Lorazepam 1 mg QHS\n Trazodone 25 mg QHS\n Albuterol nebulizers Q4H (started )\n Ipratropium nebulizers Q4H (started )\n Fluticasone inhaler 1 Puff \n Iron 1250 mg \n Lorazepam 0.5 mg daily:RPN\n Tylenol 650 mg Q4H:PRN and QHS\n Amlodipine 10 mg daily\n Cholecalciferol 1000 U daily\n Hydrochlorothiazide 25 mg daily\n Lisinopril 40 mg daily\n Insulin glargine 54 U QAM, 30 U QPM\n Calcium Carbonate 650 mg \n Venlafaxine XR 75 mg daily\n Simvastatin 40 mg daily\n Albuterol\n Past medical history:\n Family history:\n Social History:\n Lung Cancer s/p chemotherapy and lobectomy (date unknown)\n Type II Diabetes on insulin\n Macular Degeneration (legally blind)\n Hypertension\n COPD\n Breast Cancer s/p lumpectomy\n Hypercholesterolemia\n Diverticulosis\n Obesity\n Depression/Anxiety\n Anemia\n B12 deficiency\n Colon Polyps s/p polypectomy \n No history of lung disease\n Occupation: Retired.\n Drugs: None\n Tobacco: Previous, quit when diagnosed with lung cancer\n Alcohol: None\n Other: Living at rehab for one year\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: No(t) Numbness / tingling\n Psychiatric / Sleep: Agitated, No(t) Delirious\n Allergy / Immunology: No(t) Immunocompromised, Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:46 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: 102 (102 - 111) bpm\n BP: 106/60(69) {106/45(68) - 151/76(95)} mmHg\n RR: 22 (22 - 27) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n 1 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -99 mL\n 1 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n Physical Examination\n Vitals: T: 99.6 BP: 151/76 P: 111 R: 27 O2: 99% on NRB\n General: Aggitated, oriented, mild respiratory distress using abdominal\n musculature\n HEENT: Sclera anicteric, MM dry, oropharynx clear\n Neck: supple, JVP 12 cm, no LAD\n Lungs: Decreased breath sounds throughout, scarce expiratory wheezes,\n no crackles or ronchi appreciated, right sided thoracotomy scar well\n healed\n CV: Tachycardic, normal s1 + s2, no murmurs, rubs or gallops\n appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley draining clear yellow urine\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neurologic: Grossly intact\n Labs / Radiology\n 269\n 10.5\n 201\n 1.2\n 25\n 31\n 97\n 4.3\n 139\n 31.8\n 15.1\n [image002.jpg]\n Other labs: PT / PTT / INR:12.1/24.8/1.0, CK / CKMB /\n Troponin-T:126/5/0.02, Differential-Neuts:91.0, Lymph:5.2, Mono:3.1,\n Eos:0.5, Lactic Acid:1.2, Ca++:11.1, Mg++:1.9, PO4:3.0\n Fluid analysis / Other labs: BNP: 1122\n ABG: 7.44/47/51\n Imaging: CXR: Opacities at the left lung base, left upper lung, and\n right mid lung as above, these are nonspecific. Multifocal pneumonia\n is primarily considered. In addition, note is made of cardiomegaly and\n sequelae of thoracic surgery.\n Microbiology: Blood cultures x 2 pending\n UA positive, culture pending\n ECG: Sinus tachycardia, left axis, right bundle branch block, TWI\n V1-V3, q waves III, avF, no change compared to prior earlier in the\n day.\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Cough/Shortness of Breath: Questionable small infiltrate in left upper\n lung field. Also low grade fevers, leukocytosis, and upper respiratory\n tract symptoms. Likely represents exacerbation of patients known COPD\n in the setting of possible viral versus bacterial lung infection. Also\n may be a component of volume overload although no clear cardiac\n history. Pulmonary embolism must be considered in the differential\n given history of malignancy. Cardiac ischemia seems less likely given\n lack of history of chest pain.\n - vancomycin, zosyn and levofloxacin for health care associated\n pneumonia in an ICU patient\n - urine legionella\n - blood and sputum cultures\n - influenza A swab\n - droplet precautions\n - titrate nasal cannula to sats between 88-92%\n - continue solumedrol for likely COPD exacerbation\n - albuterol and ipratropium nebulizers\n - r/o MI with serial cardiac enzymes\n - repeat CXR in the AM\n - if no improvement with these measures will need to consider chest CT\n to assesss further lung parenchyma as well as to assess for pulmonary\n embolism\n Positive UA: Will check urine culture. Currently no symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n COPD: On 2L nasal cannula at baseline.\n - solumedrol 125 mg IV Q8H\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable in 110s systolic.\n - continue home blood pressure regimen with holding parameters\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin. Currently NPO.\n - will give lantus 25 U qAM and 15 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - holding trazodone\n Anemia: Unclear baseline.\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n FEN: No IVF, replete electrolytes, NPO for now\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Comments: Half of home lantus with humalog sliding\n scale\n Lines:\n 18 Gauge - 11:40 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Other)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2188-06-03 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 582968, "text": "Chief Complaint: SOB\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 78 yo women with h/o COPD presents with URI symptoms for few days,\n thick sputum. Breathing worsened over 3 days. Began getting spiriva\n nebs. In ED required 100% NRB wth sat 94%, 85% on RA. CXR: with\n multifocal infiltrates. Got vanco/zosyn,medrol, bipap,NTG,lasix. WBC\n 15.1. Did not tolerate Bipap and did well on 4L NC.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n heparin s/q\n pepcid\n atrovent\n medrol 125 q8h\n FeS04\n norvasc\n vitamin D\n SSI\n tums\n effexor\n Past medical history:\n Family history:\n Social History:\n COPD on 2L home O2\n DM II\n lung CA s/p Right lobectomy\n breat CA\n chronic anemia\n meds:\n Lorazepam\n trazadone\n albuterol\n bactrim (for 3 days)\n flovent\n hctz\n lisinopril\n effecxor\n noncontributatory for COPD\n Occupation:\n Drugs: none\n Tobacco: long smoking history\n Alcohol: none\n Other: lives at Rehab\n Review of systems:\n Constitutional: 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) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Delirious\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:02 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: 36.2\nC (97.1\n HR: 113 (99 - 113) bpm\n BP: 134/53(68) {106/45(68) - 158/76(95)} mmHg\n RR: 24 (18 - 33) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1 mL\n 101 mL\n PO:\n TF:\n IVF:\n 1 mL\n 101 mL\n Blood products:\n Total out:\n 100 mL\n 290 mL\n Urine:\n 100 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -99 mL\n -189 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.44/47/51/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): times 3, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 270 K/uL\n 30.6 %\n 9.8 g/dL\n 264 mg/dL\n 1.5 mg/dL\n 31 mg/dL\n 28 mEq/L\n 97 mEq/L\n 4.2 mEq/L\n 139 mEq/L\n 13.9 K/uL\n [image002.jpg]\n 02:54 AM\n WBC\n 13.9\n Hct\n 30.6\n Plt\n 270\n Cr\n 1.5\n TropT\n 0.02\n Glucose\n 264\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Ca++:10.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR: Multifocal infiltrates (no prior) RML, LUL\n Microbiology: legionella negative\n Assessment and Plan\n Respiratory distress: COPD exacerbation and multifocal PNA\n can wean steroids to prednisone 40mg po. Continue albuterol,\n atrovent. Continue vanco/zosyn/levoflox\n DM II: on half dose lantis because she is not eating\n acute renal failure: will try to get outside records to find out what\n her baseline hct is\n HTN: holding meds in setting of renal failure\n hypercalcemia: can hold tums\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:40 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2188-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582970, "text": "Chief Complaint:\n 24 Hour Events:\n - Patient admitted from the emergency room\n - Started on vancomycin, zosyn and levofloxaxin\n - Titrated from BIPAP to 4 liters nasal cannula\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 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 Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: Agitated\n Allergy / Immunology: No(t) Immunocompromised, Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:21 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: 36.2\nC (97.1\n HR: 102 (99 - 111) bpm\n BP: 158/56(78) {106/45(68) - 158/76(95)} mmHg\n RR: 23 (18 - 33) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 101 mL\n PO:\n TF:\n IVF:\n 1 mL\n 101 mL\n Blood products:\n Total out:\n 100 mL\n 195 mL\n Urine:\n 100 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -99 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:\n Resonant : ), (Breath Sounds: Wheezes : ), Decreased expansion on right\n secondary to lobectomy\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, year, Movement: Purposeful,\n No(t) Sedated, Tone: Normal\n Labs / Radiology\n 270 K/uL\n 9.8 g/dL\n 264 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 31 mg/dL\n 97 mEq/L\n 139 mEq/L\n 30.6 %\n 13.9 K/uL\n [image002.jpg]\n 02:54 AM\n WBC\n 13.9\n Hct\n 30.6\n Plt\n 270\n Cr\n 1.5\n TropT\n 0.02\n Glucose\n 264\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Ca++:10.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR Portable : Opacities at the left lung base, left\n upper lung, and right mid lung as above, these are nonspecific.\n Multifocal pneumonia is primarily\n considered. In addition, note is made of cardiomegaly and sequelae of\n thoracic\n surgery.\n Microbiology: Blood cultures x 2 - no growth\n Urine legionella - negative\n Urine culture - no growth\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Cough/Shortness of Breath: Questionable small infiltrate in left upper\n lung field. Also low grade fevers, leukocytosis, and upper respiratory\n tract symptoms. Likely represents exacerbation of patients known COPD\n in the setting of possible viral versus bacterial lung infection. Also\n may be a component of volume overload although no clear cardiac\n history. Pulmonary embolism must be considered in the differential\n given history of malignancy. Cardiac ischemia seems less likely given\n lack of history of chest pain. WBC count trending down with\n antibiotics. Able to wean to 4L nasal cannula. Urine legionella\n negative.\n - vancomycin, zosyn for health care associated pneumonia in an ICU\n patient\n - Continue levofloxacin for atypical coverage\n - blood, urine, sputum cultures pending\n - influenza A swab pending\n - droplet precautions until flu swab negative\n - titrate nasal cannula to sats between 88-92%\n - Change solumedrol to PO prednisone today for likely COPD exacerbation\n - albuterol and ipratropium nebulizers\n - if no improvement with these measures will need to consider chest CT\n to assesss further lung parenchyma as well as to assess for pulmonary\n embolism\n Positive UA: Will check urine culture. Currently no symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Unclear baseline\n - d/c supplemental Ca\n - Check Albumin\n Acute Renal Failure: Unclear baseline. Creatinine up to 1.5 this\n morning from 1.2 on presentation.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - no IVF for now\n COPD: On 2L nasal cannula at baseline.\n - solumedrol 125 mg IV Q8H\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine this morning. Already received AM medications.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin. Currently NPO.\n - will give lantus 25 U qAM and 15 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - holding trazodone\n Anemia: Unclear baseline. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n FEN: No IVF, replete electrolytes, low sodium diet\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Comments: Regular diet (low sodium, diabetic)\n Glycemic Control: Comments: Lantus with humalog sliding scale\n Lines:\n 18 Gauge - 11:40 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2188-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 582951, "text": "Chief Complaint:\n 24 Hour Events:\n - Patient admitted from the emergency room\n - Started on vancomycin, zosyn and levofloxaxin\n - Titrated from BIPAP to 4 liters nasal cannula\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 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 Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: Agitated\n Allergy / Immunology: No(t) Immunocompromised, Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:21 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: 36.2\nC (97.1\n HR: 102 (99 - 111) bpm\n BP: 158/56(78) {106/45(68) - 158/76(95)} mmHg\n RR: 23 (18 - 33) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1 mL\n 101 mL\n PO:\n TF:\n IVF:\n 1 mL\n 101 mL\n Blood products:\n Total out:\n 100 mL\n 195 mL\n Urine:\n 100 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -99 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:\n Resonant : ), (Breath Sounds: Wheezes : ), Decreased expansion on right\n secondary to lobectomy\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, year, Movement: Purposeful,\n No(t) Sedated, Tone: Normal\n Labs / Radiology\n 270 K/uL\n 9.8 g/dL\n 264 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 31 mg/dL\n 97 mEq/L\n 139 mEq/L\n 30.6 %\n 13.9 K/uL\n [image002.jpg]\n 02:54 AM\n WBC\n 13.9\n Hct\n 30.6\n Plt\n 270\n Cr\n 1.5\n TropT\n 0.02\n Glucose\n 264\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Ca++:10.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR Portable : Opacities at the left lung base, left\n upper lung, and right mid lung as above, these are nonspecific.\n Multifocal pneumonia is primarily\n considered. In addition, note is made of cardiomegaly and sequelae of\n thoracic\n surgery.\n Microbiology: Blood cultures x 2 - no growth\n Urine legionella - negative\n Urine culture - no growth\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Cough/Shortness of Breath: Questionable small infiltrate in left upper\n lung field. Also low grade fevers, leukocytosis, and upper respiratory\n tract symptoms. Likely represents exacerbation of patients known COPD\n in the setting of possible viral versus bacterial lung infection. Also\n may be a component of volume overload although no clear cardiac\n history. Pulmonary embolism must be considered in the differential\n given history of malignancy. Cardiac ischemia seems less likely given\n lack of history of chest pain. WBC count trending down with\n antibiotics. Able to wean to 4L nasal cannula. Urine legionella\n negative.\n - vancomycin, zosyn for health care associated pneumonia in an ICU\n patient\n - can discontinue levofloxacin\n - blood, urine, sputum cultures pending\n - influenza A swab pending\n - droplet precautions until flu swab negative\n - titrate nasal cannula to sats between 88-92%\n - continue solumedrol for likely COPD exacerbation\n - albuterol and ipratropium nebulizers\n - if no improvement with these measures will need to consider chest CT\n to assesss further lung parenchyma as well as to assess for pulmonary\n embolism\n Positive UA: Will check urine culture. Currently no symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Acute Renal Failure: Unclear baseline. Creatinine up to 1.5 this\n morning from 1.2 on presentation.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - no IVF for now\n COPD: On 2L nasal cannula at baseline.\n - solumedrol 125 mg IV Q8H\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine this morning. Already received AM medications.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin. Currently NPO.\n - will give lantus 25 U qAM and 15 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - holding trazodone\n Anemia: Unclear baseline.\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n FEN: No IVF, replete electrolytes, low sodium diet\n Prophylaxis: Subutaneous heparin\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n Disposition: ICU care for now\n ICU Care\n Nutrition:\n Comments: Regular diet (low sodium, diabetic)\n Glycemic Control: Comments: Lantus with humalog sliding scale\n Lines:\n 18 Gauge - 11:40 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 583180, "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 78 yo women with severe COPD admitted with multifocal PNA and COPD\n exacerbation.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Vancomycin - 07:54 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 AM\n Other medications:\n pepcid\n vanco\n ferrous sulfate\n vitamin D\n SSI\n effexor\n simvastatin\n zosyn\n prednisone 40mg po qd\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 09:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96\n HR: 97 (96 - 117) bpm\n BP: 121/53(70) {94/17(32) - 154/99(111)} mmHg\n RR: 23 (19 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 691 mL\n 325 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 325 mL\n Blood products:\n Total out:\n 635 mL\n 200 mL\n Urine:\n 635 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Clear : )\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, tearful\n Labs / Radiology\n 10.2 g/dL\n 325 K/uL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Much improved\n tearful/depressed: may be in part because of prednisone - will rapidly\n taper\n acute renal failure: will try fluid repletion to if it improves\n creatinine. renal lytes more consistent with intrarenal picture, but\n no clear cause\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583166, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General: Aggitated, oriented, mild respiratory distress using abdominal\n musculature\n HEENT: Sclera anicteric, MM dry, oropharynx clear\n Neck: supple, JVP 12 cm, no LAD\n Lungs: Decreased breath sounds throughout, scarce expiratory wheezes,\n no crackles or ronchi appreciated, right sided thoracotomy scar well\n healed\n CV: Tachycardic, normal s1 + s2, no murmurs, rubs or gallops\n appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley draining clear yellow urine\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neurologic: Grossly intact\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n CXR Portable : In comparison with the earlier study of this\n date, there is again an area of increased opacification in the left\n base, right mid lung, and left upper lung, suggestive of the clinical\n impression of multifocal pneumonia. Post-surgical changes are again\n seen in the right apical region.\n Microbiology:\nDIRECT INFLUENZA B ANTIGEN TEST (Final ):\n NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.\nLegionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n Blood cultures, urine cultures from \n no growth to date\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Pneumonia: Patient presented with cough, shortness of breath.\n Patient\ns chest xray consistent with multifocal pneumonia. Now urine\n legionella negative, influenza A negative. Unable to obtain sputum\n sample for culture. Now afebrile, oxygen titrated down to 3 L nasal\n cannula. Patient also likely has a component of COPD exacerbation\n given poor lung reserve at baseline- Significantly improved from\n admission.\n - continue vancomycin, zosyn, levofloxacin for 7 day course for health\n care associated pneumonia in an ICU patient\n - blood, urine cultures pending\n - attempt to send sputum sample\n - titrate nasal cannula to sats between 88-92% (on 2L at baseline)\n - decrease prednisone to 40 mg daily with plans for quick taper\n - albuterol and ipratropium nebulizers\n Acute Renal Failure: Baseline of 0.9-1.0 as of 10/. Creatinine up\n to 1.9 this morning from 1.2 on presentation. Likely prerenal in the\n setting of infection and decreased PO intake.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - will give a liter of normal saline today and recheck creatinine in AM\n - will attempt to send urine electrolytes\n Positive UA: Urine culture continues to be negative. Currently no\n symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Had been 9.8 in 10/. Now with normal albumin. Now\n down to 10.1 after discontinuing calcium supplements.\n - continue to hold supplemental calcium\n COPD: On 2L nasal cannula at baseline.\n - quick prednisone taper\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin.\n - increased lantus 45 U qAM and 25 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - continued trazodone\n Anemia: baseline 26-28. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n ICU Care\n Nutrition: low sodium/diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583167, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General: Much calmer this morning, oriented, no longer using\n significant abdominal musculature for respiration\n HEENT: Sclera anicteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Decreased breath sounds throughout, scarce expiratory wheezes,\n no crackles or ronchi appreciated, right sided thoracotomy scar well\n healed\n CV: Normal sinus rhythm, normal s1 + s2, no murmurs, rubs or gallops\n appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley draining clear yellow urine\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neurologic: Grossly intact\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n CXR Portable : In comparison with the earlier study of this\n date, there is again an area of increased opacification in the left\n base, right mid lung, and left upper lung, suggestive of the clinical\n impression of multifocal pneumonia. Post-surgical changes are again\n seen in the right apical region.\n Microbiology:\nDIRECT INFLUENZA B ANTIGEN TEST (Final ):\n NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.\nLegionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n Blood cultures, urine cultures from \n no growth to date\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Pneumonia: Patient presented with cough, shortness of breath.\n Patient\ns chest xray consistent with multifocal pneumonia. Now urine\n legionella negative, influenza A negative. Unable to obtain sputum\n sample for culture. Now afebrile, oxygen titrated down to 3 L nasal\n cannula. Patient also likely has a component of COPD exacerbation\n given poor lung reserve at baseline- Significantly improved from\n admission.\n - continue vancomycin, zosyn, levofloxacin for 7 day course for health\n care associated pneumonia in an ICU patient\n - blood, urine cultures pending\n - attempt to send sputum sample\n - titrate nasal cannula to sats between 88-92% (on 2L at baseline)\n - decrease prednisone to 40 mg daily with plans for quick taper\n - albuterol and ipratropium nebulizers\n Acute Renal Failure: Baseline of 0.9-1.0 as of 10/. Creatinine up\n to 1.9 this morning from 1.2 on presentation. Likely prerenal in the\n setting of infection and decreased PO intake.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - will give a liter of normal saline today and recheck creatinine in AM\n - will attempt to send urine electrolytes\n Positive UA: Urine culture continues to be negative. Currently no\n symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Had been 9.8 in 10/. Now with normal albumin. Now\n down to 10.1 after discontinuing calcium supplements.\n - continue to hold supplemental calcium\n COPD: On 2L nasal cannula at baseline.\n - quick prednisone taper\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin.\n - increased lantus 45 U qAM and 25 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - continued trazodone\n Anemia: baseline 26-28. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n ICU Care\n Nutrition: low sodium/diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583181, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General: Much calmer this morning, oriented, no longer using\n significant abdominal musculature for respiration\n HEENT: Sclera anicteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Decreased breath sounds throughout, scarce expiratory wheezes,\n no crackles or ronchi appreciated, right sided thoracotomy scar well\n healed\n CV: Normal sinus rhythm, normal s1 + s2, no murmurs, rubs or gallops\n appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley draining clear yellow urine\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neurologic: Grossly intact\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n CXR Portable : In comparison with the earlier study of this\n date, there is again an area of increased opacification in the left\n base, right mid lung, and left upper lung, suggestive of the clinical\n impression of multifocal pneumonia. Post-surgical changes are again\n seen in the right apical region.\n Microbiology:\nDIRECT INFLUENZA B ANTIGEN TEST (Final ):\n NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.\nLegionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n Blood cultures, urine cultures from \n no growth to date\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Pneumonia: Patient presented with cough, shortness of breath.\n Patient\ns chest xray consistent with multifocal pneumonia. Now urine\n legionella negative, influenza A negative. Unable to obtain sputum\n sample for culture. Now afebrile, oxygen titrated down to 3 L nasal\n cannula. Patient also likely has a component of COPD exacerbation\n given poor lung reserve at baseline- Significantly improved from\n admission.\n - continue vancomycin, zosyn, levofloxacin, day 3 of 7 day course for\n health care associated pneumonia in an ICU patient\n - blood, urine cultures pending\n - attempt to send sputum sample\n - titrate nasal cannula to sats between 88-92% (on 2L at baseline)\n - decrease prednisone to 20 mg daily tomorrow, then discontinue\n - standing albuterol and ipratropium nebulizers\n Acute Renal Failure: Baseline of 0.9-1.0 as of 10/. Creatinine up\n to 1.9 this morning from 1.2 on presentation. Likely prerenal in the\n setting of infection and decreased PO intake. Ddx ATN v. AIN w/ zosyn.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - will give a liter of normal saline today and recheck creatinine in AM\n - redose abx for ARF\n - f/u urine electrolytes\n Positive UA: Urine culture continues to be negative. Currently no\n symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Had been 9.8 in 10/. Now with normal albumin. Now\n down to 10.1 after discontinuing calcium supplements.\n - continue to hold supplemental calcium\n COPD: On 2L nasal cannula at baseline.\n - quick prednisone taper as above\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin.\n - increased lantus 45 U qAM and 25 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - continued trazodone\n - defer any med adjustments to primary providers\n - quick prednisone taper as above\n Anemia: baseline 26-28. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n ICU Care\n Nutrition: low sodium/diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583140, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\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 Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE II\n ANXIETY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2188-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582938, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She was not experiencing any fevers. She was given increased nebulizer\n treatments with some relief. She was not experiencing chest pain or\n pleuritic type pain. She was not experiencing nausea, vomiting,\n abdominal pain, constipation, dysuria, hematuria, leg pain or\n swelling. She does endorse some mild diarrhea. She says that her\n breathing has been getting progressively worse over the past three days\n despite increasing nebulizer and oxygen therapy (titrated to 4L). She\n appeared progressively worse and EMS was called for transport to\n . When EMS arrived she was complaining of shortness of breath.\n Initial oxygen saturations were in the low 80s and these improved to\n 94% on a non-rebreather. She was noted to have scant wheezes in her\n upper lung fields. EKG showed sinus tachycardia, right bundle branch\n block, q waves in III, avF, TWF V1-V3. She was taken to the emergency\n room.\n In the ED, initial vs were: T: 98.8 P: 113 BP: 130/84 R: 25 O2 sat: 85%\n on RA. Initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block, TWI\n V1-V3, q waves III, avF, no change compared to prior earlier in the\n day. She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1,\n combivent nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on\n BIPAP with mild improvement. She also received nitroglycerine for\n potential volume overload as well as lasix 20 mg IV x 1. Her BNP was\n elevated at 1122. Her WBC was 15.1 with 91% neutrophils. She had one\n set of negative cardiac enzymes. She was admitted to the intensive\n care unit for further management.\n On arrival to the ICU she reports that her shortness of breath has\n improved somewhat from this morning. She denies fevers, chills, chest\n pain, nausea, vomiting, abdominal pain, constipation, dysuria,\n hematuria, leg pain or swelling. Comes from rehab. Has had recent\n rhinorrhea and productive cough without fevers. Mild diarrhea at\n rehab. All other review of systems negative in detail.\n" }, { "category": "Nursing", "chartdate": "2188-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 583129, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2.0L NC, sats low 90s, RR 20s-30s, LS rhonchorous, junky\n productive cough.\n Action:\n Pt encouraged to cough and deep breath, prn nebs given. Pt on Vanco and\n Zosyn for PNA.\n Response:\n Pt maintained sats 88-92%. Pt has strong productive cough, self\n suctioning.\n Plan:\n Cont ABX, aggressive pulm toilet. Goal sats 88-92%.\n Anxiety\n Assessment:\n Pt received from day shift calm and cooperative, with much more upbeat\n mood than last night. Over the course of the night, pt became more\n anxious with labile mood swings ranging from crying to hostile and\n mean.\n Action:\n Pt given prn Ativan, and Trazadone to sleep.\n Response:\n Pt slept in small cat naps, meds seem to be ineffective. Pt very upset\n with being continuously woken up for meds, blood draws, incontinence,\n IV insertion, etc.\n Plan:\n Cont prn Ativan, ? Morphine at night for better sleeping and control of\n resp distress induced by anxiety.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt is Type diabetic. Pt on high dose steroids over last 24hrs,\n weaned to Prednisone. BS over 300s for last 24hrs.\n Action:\n Sliding scale and Lantus increased.\n Response:\n Ongoing assessment.\n Plan:\n Cont to check FS per orders, sliding scale and fixed dose.\n Of Note, pt found to be soiled in urine overnight. Foley found to be\n leaking and pt no longer wanted it in. Foley was D/C\nd and then pt was\n incontinent several times. Pt stated she knew that she had to urinate,\n but either was too sleepy or didn\nt feel like using the call bell. Pt\n currently refusing another Foley.\n" }, { "category": "Nursing", "chartdate": "2188-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 583024, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous.\n Productive cough and able to clear secretions.\n Sats in low 90s on 2L nasal cannula.\n Dyspnea on exertion.\n Action:\n Receiving Vanco and Zosyn for questionable pna.\n Response:\n As noted above.\n Plan:\n Goal sats 88-92% COPD.\n Will continue ABX as ordered.\n Will remain in MICU as respiratory status still at issue.\n ADDITIONAL INFORMATION:\n Very anxious and teary start of shift but better after napping.\n Received Ativan with good effect.\n Very DOE but able to move independently in bed.\n" }, { "category": "Nursing", "chartdate": "2188-06-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 583251, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Dispo: DNR/DNI\n Allergies: NKDA\n Access 1piv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3.0L NC, sats mid-90s, RR 20s-30s, LS rhonchorous, +\n junky productive cough- green/yellow sputum..\n Action:\n Pt encouraged to cough and deep breath, prn nebs given. Pt on\n Vanco,Zosyn, levaquin for PNA.\n Response:\n Pt maintained sats 90s-94%. Pt has strong productive cough, self\n suctioning.\n Plan:\n Cont ABX, aggressive pulm toilet. Goal sats 88-92%.\n Anxiety\n Assessment:\n Pt with extremely labile mood, crying/depressed/angry this AM, stating\nI just want to die.\n Refusing to use bedpan to urinate, urinating in\n bed, stating\nI would rather sit in it, I am so depressed.\n Angrily\n yelling at staff. A&Ox3.\n Action:\n Pt given prn Ativan, on standing Effexor. SW consult ordered.\n Emotional support offered.\n Response:\n Pt slept in small cat naps, meds seem to be ineffective. Pt very upset\n with being continuously woken up for meds, blood draws, incontinence,\n etc. Encouraged use of bedpan, pt currently able to for RN for\n needs/using bed pan. More calm/cooperative as shift went on.\n Plan:\n Cont prn Ativan, ? Morphine at night for better sleeping and control of\n resp distress induced by anxiety. SW consult.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt is Type diabetic. Pt on high dose steroids over last 24hrs,\n weaned to Prednisone. BS over 300s for last 24hrs.\n Action:\n Sliding scale and Lantus increased o/n. Covered FSBS 352 with 13 units\n , MD aware.\n Response:\n Ongoing assessment.\n Plan:\n Cont to check FS per orders, sliding scale and fixed dose.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHF/PNA\n Code status:\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, COPD, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: Lung CA s/p chemo and lobectomy (date unknown),\n Macular Degeneration (legally blind), Breast CA s/p lumpectomy,\n hypercholesterolemia, diverticulosis, obesity, depression/anxiety, B12\n defficiency, Colon polyps s/p plypectomy \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:123\n D:35\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 883 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 12:05 PM\n Potassium:\n 4.6 mEq/L\n 12:05 PM\n Chloride:\n 97 mEq/L\n 12:05 PM\n CO2:\n 29 mEq/L\n 12:05 PM\n BUN:\n 58 mg/dL\n 12:05 PM\n Creatinine:\n 1.9 mg/dL\n 12:05 PM\n Glucose:\n 319 mg/dL\n 12:05 PM\n Hematocrit:\n 31.3 %\n 04:22 AM\n Finger Stick Glucose:\n 352\n 12:00 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 7\n Transferred to: 216\n Date & time of Transfer: 1500\n" }, { "category": "Nursing", "chartdate": "2188-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 583124, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2188-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 583015, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous.\n Productive cough and able to clear secretions.\n Sats in low 90s on 2L nasal cannula.\n Dyspnea on exertion.\n Action:\n Receiving Vanco and Zosyn for questionable pna.\n Response:\n As noted above.\n Plan:\n Goal sats 88-92% COPD.\n Will continue ABX as ordered.\n Will remain in MICU as respiratory status still at issue.\n ADDITIONAL INFORMATION:\n Very anxious and teary start of shift but better after napping.\n Received Ativan with good effect.\n Very DOE but able to move independently in bed.\n" }, { "category": "Nursing", "chartdate": "2188-06-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 583233, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Dispo: DNR/DNI\n Allergies: NKDA\n Access 1piv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3.0L NC, sats mid-90s, RR 20s-30s, LS rhonchorous, +\n junky productive cough- green/yellow sputum..\n Action:\n Pt encouraged to cough and deep breath, prn nebs given. Pt on\n Vanco,Zosyn, levaquin for PNA.\n Response:\n Pt maintained sats 90s-94%. Pt has strong productive cough, self\n suctioning.\n Plan:\n Cont ABX, aggressive pulm toilet. Goal sats 88-92%.\n Anxiety\n Assessment:\n Pt with extremely labile mood, crying/depressed/angry this AM, stating\nI just want to die.\n Refusing to use bedpan to urinate, urinating in\n bed, stating\nI would rather sit in it, I am so depressed.\n Angrily\n yelling at staff. A&Ox3.\n Action:\n Pt given prn Ativan, on standing Effexor. SW consult ordered.\n Emotional support offered.\n Response:\n Pt slept in small cat naps, meds seem to be ineffective. Pt very upset\n with being continuously woken up for meds, blood draws, incontinence,\n etc. Encouraged use of bedpan, pt currently able to for RN for\n needs/using bed pan. More calm/cooperative as shift went on.\n Plan:\n Cont prn Ativan, ? Morphine at night for better sleeping and control of\n resp distress induced by anxiety. SW consult.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt is Type diabetic. Pt on high dose steroids over last 24hrs,\n weaned to Prednisone. BS over 300s for last 24hrs.\n Action:\n Sliding scale and Lantus increased o/n. Covered FSBS 352 with 13 units\n , MD aware.\n Response:\n Ongoing assessment.\n Plan:\n Cont to check FS per orders, sliding scale and fixed dose.\n" }, { "category": "Nursing", "chartdate": "2188-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 582941, "text": "Ms. is a 78 year old female with a remote history of lung cancer\n s/p lobectomy, COPD on 2L at baseline, type II diabetes and\n hypertension who presents from Rehab with shortness of breath.\n Per notes over the past weekend she developed upper respiratory tract\n symptoms with nasal congestion, and cough productive of thick sputum.\n She appeared progressively worse and EMS was called for transport to\n . Initial oxygen saturations were in the low 80s and these\n improved to 94% on a non-rebreather.\n In the ED, initial CXR showed possible infiltrate in the L upper lobe.\n EKG showed sinus tachycardia, left axis, right bundle branch block.\n She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent\n nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with\n mild improvement. She also received nitroglycerine for potential\n volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at\n 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of\n negative cardiac enzymes. She was admitted to the intensive care unit\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt transferred to MICU on BIPAP, very anxious and crying. Sats 98-100%.\n LS rhonchorous t/o, occas exp wheezes. HR NST 100s, BP 100s-1teens on\n Nitro gtt.\n Action:\n Pt weaned to non-rebreather, then to 4.0L NC. Nitro quickly weaned to\n off. Pt given nebs and Solumedrol.\n Response:\n Pt with sats 88-93% on 4.0L NC. BP started to trend back up and pt now\n started back on home BP meds. Pt states that her breathing is\n improved, but is very tearful and emotional and just wants to be\nleft\n alone.\n Plan:\n Cont aggressive pulmonary toilet, BIPAP as needed. Pt is DNR/DNI. Cont\n ABX for likely PNA and +U/A.\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583143, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n CV:\n RESP:\n Abd:\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: present), (Left DP pulse:\n Present)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Cough/Shortness of Breath: Questionable small infiltrate in left upper\n lung field. Also low grade fevers, leukocytosis, and upper respiratory\n tract symptoms. Likely represents exacerbation of patients known COPD\n in the setting of possible viral versus bacterial lung infection. Also\n may be a component of volume overload although no clear cardiac\n history. Pulmonary embolism must be considered in the differential\n given history of malignancy. Cardiac ischemia seems less likely given\n lack of history of chest pain. WBC count trending down with\n antibiotics. Able to wean to 4L nasal cannula. Urine legionella\n negative.\n - vancomycin, zosyn for health care associated pneumonia in an ICU\n patient\n - Continue levofloxacin for atypical coverage\n - blood, urine, sputum cultures pending\n - influenza A swab pending\n - droplet precautions until flu swab negative\n - titrate nasal cannula to sats between 88-92%\n - Change solumedrol to PO prednisone today for likely COPD exacerbation\n - albuterol and ipratropium nebulizers\n - if no improvement with these measures will need to consider chest CT\n to assesss further lung parenchyma as well as to assess for pulmonary\n embolism\n Positive UA: Will check urine culture. Currently no symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Unclear baseline\n - d/c supplemental Ca\n - Check Albumin\n Acute Renal Failure: Unclear baseline. Creatinine up to 1.5 this\n morning from 1.2 on presentation.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - no IVF for now\n COPD: On 2L nasal cannula at baseline.\n - solumedrol 125 mg IV Q8H\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine this morning. Already received AM medications.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin.\n - increased lantus 45 U qAM and 25 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - continued trazodone\n Anemia: baseline 26-28. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n ICU Care\n Nutrition: low sodium/diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2188-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 583148, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued Levofloxacin with Vanc/zosyn\n - Albumin normal and Ca remained elevated -> d/c'd CaCO3\n - Could not produced sputum sample\n - Rehab records show baseline Cr of 0.9-1.0 and Hct of 26-28 in\n \n - Changed to PO prednisone and SOB continued to improve\n - I/O inaccurate as she leaked around foley\n - Urine lytes ordered, but patient incontinent overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:56 AM\n Vancomycin - 09:16 AM\n Piperacillin/Tazobactam (Zosyn) - 05:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:24 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.6\nC (96.1\n HR: 100 (99 - 117) bpm\n BP: 107/48(64) {94/17(32) - 154/99(111)} mmHg\n RR: 20 (19 - 34) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 691 mL\n 50 mL\n PO:\n 240 mL\n TF:\n IVF:\n 451 mL\n 50 mL\n Blood products:\n Total out:\n 635 mL\n 0 mL\n Urine:\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 56 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n CV:\n RESP:\n Abd:\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: present), (Left DP pulse:\n Present)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 325 K/uL\n 10.2 g/dL\n 272 mg/dL\n 1.9 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.3 %\n 13.6 K/uL\n [image002.jpg]\n 02:54 AM\n 04:22 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.6\n 31.3\n Plt\n 270\n 325\n Cr\n 1.5\n 1.9\n TropT\n 0.02\n Glucose\n 264\n 272\n Other labs: PT / PTT / INR:12.2/24.7/1.0, CK / CKMB /\n Troponin-T:204/7/0.02, Albumin:3.9 g/dL, Ca++:10.1 mg/dL, Mg++:2.3\n mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 78 year old female with a history of\n lung cancer s/p lobectomy, COPD on two liters at baseline, insulin\n dependent diabetes, hypertension who presents with rhinorrhea, cough\n and shortness of breath.\n Cough/Shortness of Breath: Questionable small infiltrate in left upper\n lung field. Also low grade fevers, leukocytosis, and upper respiratory\n tract symptoms. Likely represents exacerbation of patients known COPD\n in the setting of possible viral versus bacterial lung infection. Also\n may be a component of volume overload although no clear cardiac\n history. Pulmonary embolism must be considered in the differential\n given history of malignancy. Cardiac ischemia seems less likely given\n lack of history of chest pain. WBC count trending down with\n antibiotics. Able to wean to 4L nasal cannula. Urine legionella\n negative. Influenza A swab negative\n - vancomycin, zosyn for health care associated pneumonia in an ICU\n patient\n - Continue levofloxacin for atypical coverage\n - blood, urine, sputum cultures pending\n - titrate nasal cannula to sats between 88-92%\n - Continue PO prednisone for likely COPD exacerbation\n - albuterol and ipratropium nebulizers\n - if no improvement with these measures will need to consider chest CT\n to assesss further lung parenchyma as well as to assess for pulmonary\n embolism\n Acute Renal Failure: Baseline of 0.9-1.0 as of 10/. Creatinine up\n to 1.9 this morning from 1.2 on presentation.\n - will hold lisinopril and hydrochlorothiazide for now\n - continue amlodipine\n - consider bolus although UOP will be tough to gage given incontinence\n Positive UA: Will check urine culture. Currently no symptoms.\n - currently on antibiotics for pneumonia\n - follow urine culture\n Hypercalcemia: Had been 9.8 in 10/. Now with normal albumin.\n - d/c supplemental Ca\n COPD: On 2L nasal cannula at baseline.\n - solumedrol 125 mg IV Q8H\n - albuterol/ipratropium nebulizers\n - workup as above\n Hypertension: Blood pressures currently stable but with rising\n creatinine this morning. Already received AM medications.\n - hold lisinopril and hydrochlorothiazide\n - continue amlodipine\n Lung Cancer: Details are unclear but patient is s/p chemotherapy and\n lobectomy at unknown date.\n - not currently considered an active issue at rehab\n Type II Diabetes: On insulin.\n - increased lantus 45 U qAM and 25 U qPM\n - humalog sliding scale\n Hypercholesterolemia:\n - continue statin\n Depression/Anxiety:\n - continue ativan with holding parameters\n - continue venlafaxine\n - continued trazodone\n Anemia: baseline 26-28. Stable Hct\n - continue iron supplements\n - active type and screen\n - trend hematocrit\n Access: peripherals\n Code: DNR/DNI (discussed with patient)\n Communication: (friend) \n ICU Care\n Nutrition: low sodium/diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" } ]

[ { "category": "Echo", "chartdate": "2189-05-08 00:00:00.000", "description": "Report", "row_id": 64211, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for AVR\nHeight: (in) 70\nWeight (lb): 195\nBSA (m2): 2.07 m2\nBP (mm Hg): 139/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 09:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild symmetric\nLVH. Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\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. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Severe AS (area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. of the mitral chordae (normal variant). No resting LVOT\ngradient. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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:\nPRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium or left atrial appendage.\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. There are simple atheroma in the aortic\narch. There are simple atheroma in the descending thoracic aorta. The aortic\nvalve is functionally bicuspid with fusion of the left and non-coronary cusps.\nThe aortic valve leaflets are severely thickened/deformed. There is severe\naortic valve stenosis (valve area 0.8cm2). No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion. Dr. was notified in person\nof the results in the operating room at the time of the study.\n\nPOST BYPASS There is normal biventricular systolic function. The mitral\nregurgitation is somewhat improved - now trace to mild. There is a\nbioprosthesis located in the aortic position. It appears well seated. The\nleaflets are seen poorly but in limited trans-gastric images they appear to be\nfunctioning normally. There is a trace to mild jet of perivalvular aortic\nregurgitation that is seen. The peak gradient through the aortic valve is\nabout 60 mmHg with a mean gradient of about 30 mmHg at a cardiac output of 6\nliters per minute. The calculated aortic valve area is about 1 cm2. These\nmeasurements are not within the expected range for a valve of this size (#23\nbioprosthesis). This issue was brought to Dr. attention\nintraoperatively. The thoracic aorta is intact after decannulation.\n\n\n" }, { "category": "ECG", "chartdate": "2189-05-08 00:00:00.000", "description": "Report", "row_id": 123809, "text": "Sinus rhythm. Compared to the previous tracing of voltage is less\nprominent.\n\n" }, { "category": "Radiology", "chartdate": "2189-05-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1085233, "text": " 10:06 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with small left effusion s/p AVR\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Small left effusion status post AVR.\n\n FINDINGS: In comparison with the study of , the medial aspect of the left\n hemidiaphragm is not well seen, consistent with retrocardiac atelectatic\n changes at the left base. Poor visualization of the costophrenic angles\n laterally is consistent with bilateral pleural effusions. Streaks of\n atelectasis are seen in both lower lung zones.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084787, "text": " 12:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of , the various monitoring and\n support devices have all been removed. Specifically, no evidence of\n pneumothorax. Decreasing atelectasis at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-05-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1084619, "text": " 12:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: AORTIC VALVE INSUFFICIENCY\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p AVR - please if there is concern\n wiht findings\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post AVR.\n\n FINDINGS: In comparison with study of , the patient has intact midline\n sternal sutures and aortic valve replacement. Endotracheal tube tip lies\n about 4.8 cm above the carina. Right IJ catheter extends to the upper portion\n of the SVC. Nasogastric tube extends to the upper portion of the stomach.\n Mediastinal drains are noted.\n\n Increased opacification at the left base is consistent with lower lung\n atelectatic change.\n\n\n" }, { "category": "Nursing", "chartdate": "2189-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 581109, "text": "POD 1 AVR tissue\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Alert, oriented x3. Slept in naps. C/O incisional pain .\n SR 90\ns til 5am, when he went into rapid afib 120\ns-160\n SBP 90- low 100\ns +palp pedal pulses.\n Lungs clear, diminished bases. Sats 98% on 2L nc.\n Abdomen soft, +bs. UOP qs via foley.\n Blood sugar within normal limits\n Action:\n Dilaudid .5-1mgiv\n Lopressor 10mg iv.\n Amiodarone 15mg bolus iv, then drip started at 1mg/min.\n Tolerated jello.\n Insulin gtt off. Glargine given this am.\n Response:\n Pain relieved with 1mg Dilaudid iv.\n Pt remains in afib 120\n Plan:\n Pain control.\n OOB to chair\n Rate control. Cont Amiodarone.\n Pulmonary hygiene.\n" }, { "category": "Nursing", "chartdate": "2189-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581177, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n POD #1 s/p AVR bioprosthetic. Alert, Ox3. Follows commands. MAE. Afib\n on monitor without ectopy. Amiodarone gtt at 0.5 mg/min. SBP 100-125.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2189-05-09 00:00:00.000", "description": "ICU Note - CVI", "row_id": 581211, "text": "CVICU\n HPI:\n HD2\n POD 2\n 62 M s/p AVR (23mm Porcine) \n EF:55% Wt:8.7 Cr:1.1 HgA1c:8.0\n PMH AS, ^chol, HTN, DM, L foot surgery,HIV\n HCTZ 25',Lisinopril 20',ASA 81',Verapamil 240',Kaletra 400/100mg\n 2A&2P,Creon 10mg w/meals-snacks and HS, neurontin 600TID/300HS,MVI,urea\n cream 40% top, Lantus 44 pm,Combivir 1tab 1A&1P\n : CT d/c'd, lop 25\", anti-retrovirals resumed, amio for RAF\n Chief complaint:\n PMHx:\n Current medications:\n Abacavir Sulfate 3. Acetaminophen 4. Amiodarone 5. Aspirin EC 6.\n Bisacodyl 7. CefazoLIN\n 8. Creon 10 9. Docusate Sodium 10. Furosemide 11. Gabapentin 12.\n Gabapentin 13. HYDROmorphone (Dilaudid)\n 14. Insulin 15. LaMIVudine-Zidovudine (Combivir) 16.\n Lopinavir-Ritonavir (Oral Soln) 17. Metoprolol Tartrate\n 18. Milk of Magnesia 19. Potassium Chloride 20. Ranitidine 21. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n : Extubated . RAF 140s overnight\n INVASIVE VENTILATION - START 11:50 AM\n MULTI LUMEN - START 12:00 PM\n ARTERIAL LINE - START 12:00 PM\n EKG - At 01:00 PM\n EXTUBATION - At 04:00 PM\n INVASIVE VENTILATION - STOP 04:00 PM\n Post operative day:\n HD2\n POD 2\n 62 M s/p AVR (23mm Porcine) \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:34 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:25 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.5\nC (101.3\n HR: 86 (86 - 133) bpm\n BP: 100/66(74) {100/60(71) - 125/78(90)} mmHg\n RR: 19 (8 - 21) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (5 - 19) mmHg\n Total In:\n 5,602 mL\n 637 mL\n PO:\n 120 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 4,932 mL\n 397 mL\n Blood products:\n 500 mL\n Total out:\n 1,505 mL\n 820 mL\n Urine:\n 1,015 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,097 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: (L) base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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 (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 164 K/uL\n 10.5 g/dL\n 219\n 0.9 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.1 %\n 10.4 K/uL\n [image002.jpg]\n 11:38 AM\n 12:03 PM\n 01:37 PM\n 03:40 PM\n 07:53 PM\n 02:27 AM\n 04:00 AM\n 06:00 AM\n 08:00 AM\n 12:00 PM\n WBC\n 11.8\n 10.4\n Hct\n 33.4\n 30.6\n 30.1\n Plt\n 162\n 164\n Creatinine\n 0.9\n 0.9\n TCO2\n 28\n 22\n 21\n Glucose\n 152\n 77\n 117\n 133\n 182\n 219\n Other labs: PT / PTT / INR:13.2/32.2/1.1, Lactic Acid:2.2 mmol/L\n Assessment and Plan\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR)\n Assessment and Plan: HD2\n POD 2\n 62 M s/p AVR (23mm Porcine) \n Neurologic: Neuro checks Q: 4 hr, Dilauded prn pain. OOB->chair.Resume\n preop Gabapentin. PT eval\n Cardiovascular: Aspirin, Beta-blocker, Amio loaded/Drip for RAF 140s.\n Started B-Blocker this AM. Better rate control.PWs in\n Pulmonary: IS, Encourage DB&C,IS, gentle diuresis. CTs DC'd. CXR done\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated , Cont prophylaxis/ bowel regiment\n Renal: Foley, Adequate UO, Gentle diuresis. BUN/Cr= 13/0.9\n Hematology: Stable. No issues.\n Endocrine: Started half dose of home Lantus 22units Q AM/ Humalog ss\n Infectious Disease: Check cultures, MRSA screen PND. HIV +. Resumed all\n preop Ant virals\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Pacing wires, CTs\n DC'd\n Wounds: Dry dressings\n Imaging: CXR today, post pul CXR=No PTX\n Fluids:\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Humalog SS/Lantus 22units Q PM\n Lines:\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" }, { "category": "Nursing", "chartdate": "2189-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 581008, "text": "Hx of Aortic Stenosis, replaced with 23mm bioprosthetic valve\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt received on Prop and Neo drips, NSR without ectopy, HR in 90s, CVP\n 7-8, SBP 90-100s with goal to keep < 120, epicardial wires attached but\n pacerbox off due to increased HR, pedal pulses easily palpable, Hct was\n 33 and stable; On CMV, 100%, on low volume study, initial ABG showed\n resp acidosis, increased RR to 22, lung sounds dim at bases, CTs to\n suction and draining minimal sanguinous drainage; Sedated on Prop,\n PERRLA, pain per vital signs; OGT to LCS draining bilious drainage, abd\n soft/nontender, absent BS; Foley to gravity draining yellow clear urine\n at > 100ml/hr; BG >120; Friend visited and updated on Pt\ns plan of care\n Action:\n Weaned sedation, weaned ventilator to extubate, titrate Neo/Nitro to\n keep SBP <120, Started on Insulin drip; Given IV Morphine for pain\n Response:\n Tolerated vent wean and extubated at 1600 without incident, remained\n hemodynamically stable with no signs of bleeding, BGs per insulin drip\n protocol, pain improved from to (would be comfortable if\n ), switched to IV Dilaudid, Pt lethargic, oriented x3, tolerates\n clears and PO meds including antivirals\n Plan:\n Continue to monitor hemodynamics, pulm toilet, manage pain, increase\n diet, and increase activity tomorrow, follow strict antiviral therapy,\n ?transfer to floor\n" }, { "category": "Respiratory ", "chartdate": "2189-05-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 581006, "text": "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: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: regular and unlabored\n Assessment of breathing comfort: No claim of dyspnea)\n Pt received intubated S/P AVR and vented per resp flowsheet. Stable\n post-op and fast track weaned to extubation. Pt currently on 2L NP with\n good sats.\n" }, { "category": "Nursing", "chartdate": "2189-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581185, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n POD #1 s/p AVR bioprosthetic. Tmax 101.3. Alert, Ox3. Follows\n commands. MAE. Afib on monitor without ectopy. Amiodarone gtt at 0.5\n mg/min. SBP 100-125. LS clear, diminished at bases. CTs d/c\nd at 1300.\n CXR completed post removal. O2 at 2L NC with O2 sats > 95%. CDB/IS\n independently with good effort. Abd soft, NT. Positive bowel sounds.\n Negative flatus. Foley with adequate hourly urine amount, clear yellow.\n Glucose elevated at lunchtime 219. aware. Given add\nl sc\n lantus 22 units and 14 units sc humalog. Written for pt specific\n sliding scale. Pain managed with PO dilaudid. Currently a at\n incisional site. OOB to chair with 2 person assist. Tolerated activity\n without issue. OOB to chair from today. Pt\ns family member, ,\n notified of pt status, updated on POC. Supportive. Pt aware of transfer\n to floor.\n Action:\n Tylenol 650 mg acetaminophen for temp. aware. Continues on\n Amiodarone gtt. To be turned off at 6/21 at 0600. Started on PO\n lopressor 25 mg .\n Response:\n Rate down to 90s Afib post lopressor. Current pain .\n Plan:\n Glucose control. Pain management. Pulmonary hygiene. Post op education.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT /SDA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: HIV +, Aortic Stenosis\n Surgery / Procedure and date: AVR with 23mm bioprosthetic\n valve, easy intubation, CPBT 90\", XCLT 69\", 2700ml of CRYST, 500ml of\n CS, on PROP/NEO, 2A/2V wires, mediastinal CTs\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:66\n Temperature:\n 101.3\n Arterial BP:\n S:101\n D:60\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\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 626 mL\n 24h total out:\n 820 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Pacer Turned Off\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 138 mEq/L\n 02:27 AM\n Potassium:\n 4.1 mEq/L\n 02:27 AM\n Chloride:\n 106 mEq/L\n 02:27 AM\n CO2:\n 27 mEq/L\n 02:27 AM\n BUN:\n 13 mg/dL\n 02:27 AM\n Creatinine:\n 0.9 mg/dL\n 02:27 AM\n Glucose:\n 219\n 12:00 PM\n Hematocrit:\n 30.1 %\n 02:27 AM\n Finger Stick Glucose:\n 87\n 02:30 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley catheter; #18 PIV R FA inserted .\n Valuables / Signature\n Patient valuables:\n Other valuables: black backpack, blackberry, bag with clothes.\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 774\n Transferred to: 6 611-A\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2189-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581181, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n POD #1 s/p AVR bioprosthetic. Tmax 101.3. Alert, Ox3. Follows\n commands. MAE. Afib on monitor without ectopy. Amiodarone gtt at 0.5\n mg/min. SBP 100-125. LS clear, diminished at bases. CTs d/c\nd at 1300.\n CXR completed post removal. O2 at 2L NC with O2 sats > 95%. CDB/IS\n independently with good effort. Abd soft, NT. Positive bowel sounds.\n Negative flatus. Foley with adequate hourly urine amount, clear yellow.\n Glucose elevated at lunchtime 219. aware. Given add\nl sc\n lantus 22 units and 14 units sc humalog. Written for pt specific\n sliding scale. Pain managed with PO dilaudid. Currently a at\n incisional site. OOB to chair with 2 person assist. Tolerated activity\n without issue. OOB to chair from today. Pt\ns family member, ,\n notified of pt status, updated on POC. Supportive. Pt aware of transfer\n to floor.\n Action:\n Tylenol 650 mg acetaminophen for temp. aware. Continues on\n Amiodarone gtt. To be turned off at 6/21 at 0600. Started on PO\n lopressor 25 mg .\n Response:\n Rate down to 90s Afib post lopressor. Current pain .\n Plan:\n Glucose control. Pain management. Pulmonary hygiene.\n" }, { "category": "Nursing", "chartdate": "2189-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 581183, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n POD #1 s/p AVR bioprosthetic. Tmax 101.3. Alert, Ox3. Follows\n commands. MAE. Afib on monitor without ectopy. Amiodarone gtt at 0.5\n mg/min. SBP 100-125. LS clear, diminished at bases. CTs d/c\nd at 1300.\n CXR completed post removal. O2 at 2L NC with O2 sats > 95%. CDB/IS\n independently with good effort. Abd soft, NT. Positive bowel sounds.\n Negative flatus. Foley with adequate hourly urine amount, clear yellow.\n Glucose elevated at lunchtime 219. aware. Given add\nl sc\n lantus 22 units and 14 units sc humalog. Written for pt specific\n sliding scale. Pain managed with PO dilaudid. Currently a at\n incisional site. OOB to chair with 2 person assist. Tolerated activity\n without issue. OOB to chair from today. Pt\ns family member, ,\n notified of pt status, updated on POC. Supportive. Pt aware of transfer\n to floor.\n Action:\n Tylenol 650 mg acetaminophen for temp. aware. Continues on\n Amiodarone gtt. To be turned off at 6/21 at 0600. Started on PO\n lopressor 25 mg .\n Response:\n Rate down to 90s Afib post lopressor. Current pain .\n Plan:\n Glucose control. Pain management. Pulmonary hygiene. Post op education.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n AORTIC VALVE INSUFFICIENCY AORTIC VALVE REPLACEMENT /SDA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: HIV +, Aortic Stenosis\n Surgery / Procedure and date: AVR with 23mm bioprosthetic\n valve, easy intubation, CPBT 90\", XCLT 69\", 2700ml of CRYST, 500ml of\n CS, on PROP/NEO, 2A/2V wires, mediastinal CTs\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:66\n Temperature:\n 101.3\n Arterial BP:\n S:101\n D:60\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\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 626 mL\n 24h total out:\n 820 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Pacer Turned Off\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 138 mEq/L\n 02:27 AM\n Potassium:\n 4.1 mEq/L\n 02:27 AM\n Chloride:\n 106 mEq/L\n 02:27 AM\n CO2:\n 27 mEq/L\n 02:27 AM\n BUN:\n 13 mg/dL\n 02:27 AM\n Creatinine:\n 0.9 mg/dL\n 02:27 AM\n Glucose:\n 219\n 12:00 PM\n Hematocrit:\n 30.1 %\n 02:27 AM\n Finger Stick Glucose:\n 87\n 02:30 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley catheter; #18 PIV R FA inserted .\n Valuables / Signature\n Patient valuables:\n Other valuables: black backpack, blackberry, bag with clothes.\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 774\n Transferred to: 6 611-A\n Date & time of Transfer: 12:00 AM\n" } ]

[ { "category": "Nursing", "chartdate": "2148-05-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685243, "text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt transferred from 10 after becoming hypotensive to\n 70\ns in dialysis\n Pt having large volume of drainage via JP= pale yellow in\n color\n Midline incision clean and dry ( post- bilateral nephrectomy\n on )\n Fistula right upper arm\n Action:\n Abd CT done\n Albumin 5% = 500cc q8hrs given\n Jp drainage replaced with\n cc/cc 0,45 normal saline\n Hemodynamics monitored\n Blood culture sent\n Response:\n Sbp 79-96\n Continue to have large JP output\n Plan:\n Continue to replace jp output as ordered\n Administer albumin as ordered\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt has H/ O stroke- with right sided weakness\n States right arm is weaker than right leg\n Action:\n Pt assisted when turning\n Neuro status monitored\n Response:\n Unchanged\n Pt alert and oriented x3\n Plan:\n Ongoing evaluation\n Assist with ADL\ns as needed\n" }, { "category": "Physician ", "chartdate": "2148-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 682463, "text": "SICU\n HPI:\n 62F c ESRD secondary to polycystic kidney disease, s/p bilateral\n nephrectomy for pain\n Chief complaint:\n fluid shifts intra-op, transfusion requirement in PACU\n PMHx:\n PMH: h/o CVA, brain aneurysm, ESRD secondary to PKD\n PSH: appy, TAH, RUE AVF\n Current medications:\n 1. 2. 1000 mL D5 1/2NS 3. Acetaminophen 4. CefazoLIN 5. Docusate Sodium\n 6. HYDROmorphone (Dilaudid)\n 7. Heparin 8. Levothyroxine Sodium 9. Metoprolol Tartrate 10.\n NIFEdipine CR 11. Nephrocaps 12. Ondansetron\n 13. Sodium Chloride 0.9% Flush 14. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n admit to SICU, intraop:2uPRBC,1FFP / postop 2RBC,1FFP,1cryo,\n Allergies:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.3\nC (95.6\n HR: 83 (81 - 91) bpm\n BP: 119/69(85) {116/63(83) - 132/71(92)} mmHg\n RR: 13 (11 - 18) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,353 mL\n 198 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 4,050 mL\n 198 mL\n Blood products:\n 3,183 mL\n Total out:\n 2,530 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n 1,140 mL\n 800 mL\n Balance:\n 4,823 mL\n -602 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///18/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: appropriately, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 148 K/uL\n 11.3 g/dL\n 153 mg/dL\n 4.0 mg/dL\n 18 mEq/L\n 5.0 mEq/L\n 31 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.0 %\n 10.0 K/uL\n [image002.jpg]\n 10:46 PM\n 02:03 AM\n WBC\n 10.0\n Hct\n 30.2\n 33.0\n Plt\n 134\n 148\n Creatinine\n 4.0\n Glucose\n 153\n Other labs: PT / PTT / INR:16.0/33.3/1.4, ALT / AST: 207/254, Alk-Phos\n / T bili:38/0.8, Fibrinogen:332 mg/dL, Albumin:3.6 g/dL, Ca:8.6 mg/dL,\n Mg:1.8 mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), PAIN CONTROL\n (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 62F c ESRD secondary to polycystic kidney disease,\n s/p bilateral nephrectomy for pain\n Neurologic: dilaudid PCA, tylenol prn\n Cardiovascular: nifedipine 30', metoprolol 25'', no active issues\n Pulmonary: pulm toilet, OOB w/assist, wean o2 as tolerated\n Gastrointestinal / Abdomen: Mild transaminase elevation post-op, most\n likely brief hypotension periop, cont to trend.\n Nutrition: Clears, bowel regimen\n Renal: no Foley (bilateral nephrectomies), HD w/AVF. sevelamer 800\n TID w/meals, nephrocaps 1'\n Hematology: on SQH, Hct 22>30>32 s/p 4 upRBCs, INR 1.5 s/p 2uFFP\n Q8-12 hour Hct check today.\n Endocrine: BS q6h, RISS\n Infectious Disease: ancef x24h, WBC 10, afebrile\n Lines / Tubes / Drains: , , JPx2\n Wounds: Dry dressings\n Imaging: none\n Fluids: D5 1/2NS 50cc/h\n Consults: Transplant Surgery\n Billing Diagnosis: Respiratory insufficiency, post-op\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:37 PM\n Arterial Line - 07:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32\n" }, { "category": "Physician ", "chartdate": "2148-05-18 00:00:00.000", "description": "Intensivist Note", "row_id": 682422, "text": "SICU\n HPI:\n 62F c ESRD secondary to polycystic kidney disease, s/p bilateral\n nephrectomy for pain\n Chief complaint:\n fluid shifts intra-op, transfusion requirement in PACU\n PMHx:\n PMH: h/o CVA, brain aneurysm, ESRD secondary to PKD\n PSH: appy, TAH, RUE AVF\n Current medications:\n 1. 2. 1000 mL D5 1/2NS 3. Acetaminophen 4. CefazoLIN 5. Docusate Sodium\n 6. HYDROmorphone (Dilaudid)\n 7. Heparin 8. Levothyroxine Sodium 9. Metoprolol Tartrate 10.\n NIFEdipine CR 11. Nephrocaps 12. Ondansetron\n 13. Sodium Chloride 0.9% Flush 14. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n admit to SICU, intraop:2uPRBC,1FFP / postop 2RBC,1FFP,1cryo,\n Allergies:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.4\nC (95.8\n T current: 35.3\nC (95.6\n HR: 83 (81 - 91) bpm\n BP: 119/69(85) {116/63(83) - 132/71(92)} mmHg\n RR: 13 (11 - 18) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,353 mL\n 198 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 4,050 mL\n 198 mL\n Blood products:\n 3,183 mL\n Total out:\n 2,530 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n 1,140 mL\n 800 mL\n Balance:\n 4,823 mL\n -602 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///18/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Tender: appropriately, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 148 K/uL\n 11.3 g/dL\n 153 mg/dL\n 4.0 mg/dL\n 18 mEq/L\n 5.0 mEq/L\n 31 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.0 %\n 10.0 K/uL\n [image002.jpg]\n 10:46 PM\n 02:03 AM\n WBC\n 10.0\n Hct\n 30.2\n 33.0\n Plt\n 134\n 148\n Creatinine\n 4.0\n Glucose\n 153\n Other labs: PT / PTT / INR:16.0/33.3/1.4, ALT / AST:207/254, Alk-Phos /\n T bili:38/0.8, Fibrinogen:332 mg/dL, Albumin:3.6 g/dL, Ca:8.6 mg/dL,\n Mg:1.8 mg/dL, PO4:5.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), PAIN CONTROL\n (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 62F c ESRD secondary to polycystic kidney disease,\n s/p bilateral nephrectomy for pain\n Neurologic: dilaudid PCA, tylenol prn\n Cardiovascular: nifedipine 30', metoprolol 25'', no active issues\n Pulmonary: pulm toilet, OOB w/assist, wean o2 as tolerated\n Gastrointestinal / Abdomen:\n Nutrition: Clears, bowel regimen\n Renal: no Foley (bilateral nephrectomies), HD w/AVF. sevelamer 800\n TID w/meals, nephrocaps 1'\n Hematology: on SQH, Hct 22>30>32 s/p 4 upRBCs, INR 1.5 s/p 2uFFP\n Endocrine: BS q6h\n Infectious Disease: ancef x24h, WBC 10, afebrile\n Lines / Tubes / Drains: , , CVL, JPx2\n Wounds: Dry dressings\n Imaging: none\n Fluids: D5 1/2NS 50cc/h\n Consults: Transplant Surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 06:37 PM\n Arterial Line - 07:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2148-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682428, "text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient POD 1 bilateral nephrectomy. Lower abdominal incision dressing\n dry & intact. Bilat JPs in place. Left JP with large amount serosang\n drainage, Right JP with minimal drainage. Received 2 u prbcs & 1 u\n cryo in evening (started in pacu). HR 80\ns normal sinus & SBP\n 110-120\ns. Slightly hypothermic, temp 95-96 (patient without\n complaints). Lung sounds clear, breathing unlabored. Patient\n oriented, baseline right side weakness.\n Action:\n Labs sent as ordered. Routine postoperative monitoring. Following\n I&Os.\n Response:\n AM HCT 34, awaiting rest of AM labs. All vitals remain stable.\n Plan:\n HD today and transfer to floor.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient stating no pain @ rest. Complaining of pain after\n movement/repositioning, rating .\n Action:\n Encouraged patient to use Dilaudid pca. Assisted with positioning for\n comfort.\n Response:\n Patient using PCA appropriately, appeared comfortable overnight\n (sleeping on/off).\n Plan:\n Continue with current pain management until patient taking more po\n then switch to po pain med. Continue to provide support.\n" }, { "category": "Nursing", "chartdate": "2148-05-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 682541, "text": "Renal failure, End stage (End stage renal disease, ESRD)/\n Assessment:\n Patient s/p bilateral nephrectomy , ESRD due to polycystic kidney\n disease.\n Kidney removed for pain\n Intraop some blood loss, recovered on PACU and then transferred to SICU\n for overnight monitoring\n and fluid management.\n Given 4 u pc between PACU and SICU.\n Hct stable this am @ 31\n Patient also with some right sided weakness and slow speech at times\n (due to aneurysm clipping\n)\n Action:\n Pain well controlled on dilaudid PCA .12/6/1.2\n OOB to chair, did very well\n Diet at clears at this point, tolerating well\n Belly firm and distended, midline and 2 small bilateral side incisions\n clean/dry with original dressing intact.\n 2 large JP to self suction, left draining more than right,\n serous/ascetic like fluid\n Response:\n Recovering well\n Hemodialysis today\n Transfer to floor after dialysis\n Plan:\n As above\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n POLYCYSTIC KIDNEY DISEASE/SDA\n Code status:\n Height:\n Admission weight:\n 61 kg\n Daily weight:\n 59.1 kg\n Allergies/Reactions:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Precautions:\n PMH: Anemia, HEMO or PD, Renal Failure\n CV-PMH: CVA, Hypertension\n Additional history: hypothyroidism, aneurysm-> residual right sided\n weakness and aphasia, polycystic kidneys, R fistula (dialysis 3 x\n week),\n Surgery / Procedure and date: bilateral nephrectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 97.6\n Arterial BP:\n S:130\n D:73\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 93 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 24h total in:\n 1,028 mL\n 24h total out:\n 1,025 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:03 AM\n Potassium:\n 5.0 mEq/L\n 02:03 AM\n Chloride:\n 107 mEq/L\n 02:03 AM\n CO2:\n 18 mEq/L\n 02:03 AM\n BUN:\n 31 mg/dL\n 02:03 AM\n Creatinine:\n 4.0 mg/dL\n 02:03 AM\n Glucose:\n 153 mg/dL\n 02:03 AM\n Hematocrit:\n 31.1 %\n 08:13 AM\n Finger Stick Glucose:\n 164\n 10:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cane, brace and clothes brought up by transport\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: Hemo and then to \n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2148-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682415, "text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient POD 1 bilateral nephrectomy. Lower abdominal incision dressing\n dry & intact. Bilat JPs in place. Left JP with large amount serosang\n drainage, Right JP with minimal drainage. Received 2 u prbcs & 1 u\n cryo in evening (started in pacu). HR 80\ns normal sinus & SBP\n 110-120\ns. Slightly hypothermic, temp 95-96 (patient without\n complaints). Lung sounds clear, breathing unlabored. Patient\n oriented, baseline right side weakness.\n Action:\n Labs sent as ordered. Routine postoperative monitoring. Following\n I&Os.\n Response:\n AM HCT 34, awaiting rest of AM labs. All vitals remain stable.\n Plan:\n HD today and transfer to floor.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2148-05-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 685210, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diet: regular, renal with renal frappe supplements\n Wt: 61kg\n PMHx: CVA, brain aneurysm, ESRD PCKD, TAH, RUE AVF\n 62 y.o. F with ESRD on HD, s/p bilateral nephrectomy for pain.\n Screening patient per hospital policy. Unable to speak with patient at\n this time, however patient has had a good appetite RN notes from\n . Will follow up with po intake and tolerance. Please page\n nutrition with any problems. #\n" }, { "category": "Nursing", "chartdate": "2148-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685287, "text": "Patient transferred from floor after becoming hypotensive in dialysis.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient alert and orientated X 3 , lungs clear, systolic b/p 90-100\n over 50\ns, abd distended, + bowel sounds + bm + flatus, incision clean\n dry and staples intact, jp to bulb suction.\n Action:\n Continue with albumin and\n cc to 1 cc replacement.\n Response:\n Patient condition remains unchanged. Abd Ct per transplant resident\n showed no clot in portal vein.\n Plan:\n Continue with current treatment report any changes to Sicu team provide\n comfort and support as needed. ? Transfer back to floor.\n" }, { "category": "Physician ", "chartdate": "2148-05-31 00:00:00.000", "description": "Intensivist Note", "row_id": 685293, "text": "SICU\n HPI:\n 62F c ESRD secondary to polycystic kidney disease, s/p bilateral\n nephrectomy for pain, w/ high output from abd drain and\n orthostasis\n Chief complaint:\n orthostasis\n PMHx:\n h/o CVA, ESRD, HTN, right hemiplegia secondary to aneurism\n rupture secondary to PKD\n Current medications:\n Levothyroxine Sodium 100 mcg PO DAILY\n Levofloxacin 250 mg PO Q48H\n Midodrine 5 mg PO BID Order date: @ 1203\n Nephrocaps 1 CAP PO DAILY Order date: @ 1203\n Albumin 5% (25g / 500mL) 25 g IV Q8H large ascites output Order date:\n @ 1207 16.\n Omeprazole 20 mg PO DAILY reflux Order date: @ 1203\n Bisacodyl 10 mg PR HS:PRN constipation Order date: @ 1203 17.\n Senna 1 TAB PO BID:PRN constipation Order date: @ 1203\n Calcium Carbonate 500 mg PO QID:PRN heartburn Order date: @ 1203\n 18.\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1203\n 8. Docusate Sodium 100 mg PO BID Order date: @ 1203 19. Sodium\n Chloride 1 gm PO BID Order date: @ 1203\n 9. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain Order date: @\n 1203 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Heparin 5000 UNIT SC BID Order date: @ 1203 21.\n sevelamer HYDROCHLORIDE 2400 mg PO TID W/MEALS\n 24 Hour Events:\n Allergies:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 95 (95 - 109) bpm\n BP: 95/59(67) {75/48(57) - 100/62(70)} mmHg\n RR: 12 (10 - 22) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 66.7 kg (admission): 65.7 kg\n Total In:\n 6,859 mL\n 611 mL\n PO:\n 270 mL\n Tube feeding:\n IV Fluid:\n 1,789 mL\n 611 mL\n Blood products:\n 1,000 mL\n Total out:\n 4,915 mL\n 750 mL\n Urine:\n NG:\n Stool:\n Drains:\n 4,915 mL\n 750 mL\n Balance:\n 1,944 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///27/\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, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 209 K/uL\n 12.3 g/dL\n 78 mg/dL\n 2.8 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 37.0 %\n 9.9 K/uL\n [image002.jpg]\n 01:29 PM\n WBC\n 9.9\n Hct\n 37.0\n Plt\n 209\n Creatinine\n 2.8\n Glucose\n 78\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), .H/O CVA\n (STROKE, CEREBRAL INFARCTION), OTHER\n Assessment and Plan: PLAN: 62F c ESRD secondary to polycystic kidney\n disease, s/p bilateral nephrectomy for pain, w/ high output from\n abd drain, orthostasis\n Neuro: AAO, dilaudid PO\n CVS: MAPs 70's, cont. albumin, midodrine\n Pulm: pulm toilet\n GI: PPI, bowel regimen\n FEN: renal diet, 1/2 cc/cc replacement of JP output\n Renal: nephro caps, sevelamer, dialysis\n Heme: SQH, Hct Q8\n Endo: TSH 19, levothyroxine 100mcg per endocrine, cortisol level\n ID: Levaquin empirically, pan cx P\n TLD: L PIV, R fistula, JP x1\n Wounds: abd\n Imaging: CT abd: no portal vein thrombus, CXR P\n Prophylaxis: boots, SQH\n Consults: West 1 Surgery, Endocrine, Nephrology\n Code: Full\n Disposition: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2148-05-31 00:00:00.000", "description": "Transfer Note", "row_id": 685379, "text": "Pt is a 62 year old woman with pmh significant for polycystic kidney\n disease known to 10\n s/p bilateral nephrectomy on .\n Readmitted to SICU on from HD where she was hypotensive (sbp 68-78)\n and had increased jp drainage. Uneventful course in SICU overnight\n given albumin q8 hours and continued with 1/2cc:cc hourly fluid\n repletion of jp drainage.\n Allergies: Iodine, Trileptal, Dilantin\n PMH: anemia, HD 3x/week (T,R,Sat)\n right av fistula, CVA, HTN,\n hypothyroidism, aneurysm - residual right sided weakness and aphasia,\n polycystic kidneys\n Neuro: A&O x3. Moves around in bed independently and OOB with\n supervision\n steady gait\n right-sided weakness baseline. Reporting\n abdominal pain, but denying need for analgesia.\n CV: HRRR, BP stable (sbp 90-100\ns). Abdominal JP with 100-1000cc/hour\n serous output\n increases with activity\n repleting as ordered.\n Resp: LSCTA. RRR. O2 sats wnl room air.\n GI: Abdomen soft/nd/appropriately tender to palpation. Tolerating renal\n diet without incident. Small formed, brown BM .\n Social: Supportive husband .\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n POLYCYSTIC KIDNEY DISEASE/SDA\n Code status:\n Height:\n Admission weight:\n 65.7 kg\n Daily weight:\n 66.7 kg\n Allergies/Reactions:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Precautions:\n PMH: Anemia, HEMO or PD, Renal Failure\n CV-PMH: CVA, Hypertension\n Additional history: hypothyroidism, aneurysm= residual right sided\n weakness and aphasia, polycystic kidneys, right fistula ( dialysis\n 3x week)\n Surgery / Procedure and date: bilateral nephrectomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:65\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 4,614 mL\n 24h total out:\n 4,200 mL\n Pertinent Lab Results:\n Sodium:\n 129 mEq/L\n 04:40 AM\n Potassium:\n 3.5 mEq/L\n 04:40 AM\n Chloride:\n 98 mEq/L\n 04:40 AM\n CO2:\n 25 mEq/L\n 04:40 AM\n BUN:\n 13 mg/dL\n 04:40 AM\n Creatinine:\n 3.4 mg/dL\n 04:40 AM\n Glucose:\n 84 mg/dL\n 04:40 AM\n Hematocrit:\n 30.5 %\n 04:40 AM\n Finger Stick Glucose:\n 110\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 10\n Date & time of Transfer: 1320\n" }, { "category": "Nursing", "chartdate": "2148-05-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 685374, "text": "Pt is a 62 year old woman with pmh significant for polycystic kidney\n disease known to 10\n s/p bilateral nephrectomy on .\n Readmitted to SICU on from HD where she was hypotensive (sbp 68-78)\n and had increased jp drainage. Uneventful course in SICU overnight\n given albumin q8 hours and continued with 1/2cc:cc hourly fluid\n repletion of jp drainage.\n Allergies: Iodine, Trileptal, Dilantin\n PMH: anemia, HD 3x/week (T,R,Sat)\n right av fistula, CVA, HTN,\n hypothyroidism, aneurysm - residual right sided weakness and aphasia,\n polycystic kidneys\n Neuro: A&O x3. Moves around in bed independently and OOB with\n supervision\n steady gait\n right-sided weakness baseline. Reporting\n abdominal pain, but denying need for analgesia.\n CV: HRRR, BP stable (sbp 90-100\ns). Abdominal JP with 100-1000cc/hour\n serous output\n increases with activity\n repleting as ordered.\n Resp: LSCTA. RRR. O2 sats wnl room air.\n GI: Abdomen soft/nd/appropriately tender to palpation. Tolerating renal\n diet without incident. Small formed, brown BM .\n Social: Supportive husband .\n" }, { "category": "Nursing", "chartdate": "2148-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685267, "text": "Patient transferred from floor after becoming hypotensive in dialysis.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient alert and orientated , lungs clear, systolic b/p 90-100 over\n 50\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2148-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685268, "text": "Patient transferred from floor after becoming hypotensive in dialysis.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient alert and orientated X 3 , lungs clear, systolic b/p 90-100\n over 50\ns, abd distended, + bowel sounds + bm + flatus, incision clean\n dry and staples intact, jp to bulb suction.\n Action:\n Continue with albumin and\n cc to 1 cc replacement.\n Response:\n Patient condition remains unchanged.\n Plan:\n Continue with current treatment report any changes to Sicu team provide\n comfort and support as needed.\n" }, { "category": "Physician ", "chartdate": "2148-05-31 00:00:00.000", "description": "Intensivist Note", "row_id": 685348, "text": "SICU\n HPI:\n 62F c ESRD secondary to polycystic kidney disease, s/p bilateral\n nephrectomy for pain, w/ high output from abd drain and\n orthostasis\n Chief complaint:\n orthostasis\n PMHx:\n h/o CVA, ESRD, HTN, right hemiplegia secondary to aneurism\n rupture secondary to PKD\n Current medications:\n Levothyroxine Sodium 100 mcg PO DAILY\n Levofloxacin 250 mg PO Q48H\n Midodrine 5 mg PO BID Order date: @ 1203\n Nephrocaps 1 CAP PO DAILY Order date: @ 1203\n Albumin 5% (25g / 500mL) 25 g IV Q8H large ascites output Order date:\n @ 1207 16.\n Omeprazole 20 mg PO DAILY reflux Order date: @ 1203\n Bisacodyl 10 mg PR HS:PRN constipation Order date: @ 1203 17.\n Senna 1 TAB PO BID:PRN constipation Order date: @ 1203\n Calcium Carbonate 500 mg PO QID:PRN heartburn Order date: @ 1203\n 18.\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1203\n 8. Docusate Sodium 100 mg PO BID Order date: @ 1203 19. Sodium\n Chloride 1 gm PO BID Order date: @ 1203\n 9. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain Order date: @\n 1203 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Heparin 5000 UNIT SC BID Order date: @ 1203 21.\n sevelamer HYDROCHLORIDE 2400 mg PO TID W/MEALS\n 24 Hour Events:\n Allergies:\n Iodine; Iodine Containing\n Unknown;\n Trileptal (Oral) (Oxcarbazepine)\n Nausea/Vomiting\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 95 (95 - 109) bpm\n BP: 95/59(67) {75/48(57) - 100/62(70)} mmHg\n RR: 12 (10 - 22) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 66.7 kg (admission): 65.7 kg\n Total In:\n 6,859 mL\n 611 mL\n PO:\n 270 mL\n Tube feeding:\n IV Fluid:\n 1,789 mL\n 611 mL\n Blood products:\n 1,000 mL\n Total out:\n 4,915 mL\n 750 mL\n Urine:\n NG:\n Stool:\n Drains:\n 4,915 mL\n 750 mL\n Balance:\n 1,944 mL\n -139 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///27/\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, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 209 K/uL\n 12.3 g/dL\n 78 mg/dL\n 2.8 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 37.0 %\n 9.9 K/uL\n [image002.jpg]\n 01:29 PM\n WBC\n 9.9\n Hct\n 37.0\n Plt\n 209\n Creatinine\n 2.8\n Glucose\n 78\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), .H/O CVA\n (STROKE, CEREBRAL INFARCTION), OTHER\n Assessment and Plan: PLAN: 62F c ESRD secondary to polycystic kidney\n disease, s/p bilateral nephrectomy for pain, w/ high output from\n abd drain, orthostasis\n Neuro: AAO, dilaudid PO\n CVS: MAPs 70's, cont. albumin, midodrine\n Pulm: pulm toilet\n GI: PPI, bowel regimen\n FEN: renal diet, 1/2 cc/cc replacement of JP output\n Renal: nephro caps, sevelamer, dialysis\n Heme: SQH, Hct Q8\n Endo: TSH 19, levothyroxine 100mcg per endocrine, cortisol level\n ID: Levaquin empirically, pan cx P\n TLD: L PIV, R fistula, JP x1\n Wounds: abd\n Imaging: CT abd: no portal vein thrombus, CXR P\n Prophylaxis: boots, SQH\n Consults: West 1 Surgery, Endocrine, Nephrology\n Code: Full\n Disposition: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n ------ Protected Section ------\n Pt seen and examined on rounds. Hypotension now improved, and\n probably secondary to dialysis. On albumin and midodrine. OK to go\n to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:36 ------\n" }, { "category": "Echo", "chartdate": "2148-05-28 00:00:00.000", "description": "Report", "row_id": 95441, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension 10 days s/p nephrectomy.\nHeight: (in) 66\nWeight (lb): 127\nBSA (m2): 1.65 m2\nBP (mm Hg): 86/62\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 16:10\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nIncidental note is made of hypoechoic structures in the liver.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF\n(>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Small RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch.\n\nAORTIC VALVE: Normal 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.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging\nsuggests a low normal left ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size is small and free wall motion is normal. The\nascending aorta is mildly dilated. The aortic arch is mildly dilated. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no pericardial effusion.\n\nVentricles appears small and hyperdynamic consistent with marked volume\ndepletion. Ordering APN notified by phone.\n\n\n" }, { "category": "ECG", "chartdate": "2148-05-28 00:00:00.000", "description": "Report", "row_id": 252151, "text": "Sinus rhythm. Small non-diagnostic inferolateral Q waves. Diffuse T wave\nflattening which is non-specific. Compared to the previous tracing of \ndiffuse T wave flattening is now more prominent.\n\n" }, { "category": "Radiology", "chartdate": "2148-05-22 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1085473, "text": " 4:15 PM\n DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Evaluate hepatic vasculature and portal vein for thrombosis\n Admitting Diagnosis: POLYCYSTIC KIDNEY DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62F with polycystic liver s/p bilateral nephrectomy for polycystic kidney\n disease for pain now with elevated LFT's\n REASON FOR THIS EXAMINATION:\n Evaluate hepatic vasculature and portal vein for thrombosis and bile duct\n dilatation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRSg WED 5:27 PM\n Limited examination due to polycystic liver disease replacing the liver with\n innumerable cysts. Gross patency of portal and hepatic veins, and hepatic\n arteries.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Polycystic liver, status post bilateral nephrectomy for\n polycystic kidney disease, now with elevated LFTs. Evaluate hepatic\n vasculature and portal vein for thrombosis and biliary dilation.\n\n COMPARISON: .\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n FINDINGS: Evaluation of the liver is again markedly limited due to diffuse\n replacement by innumerable cysts compatible with history of polycystic liver\n disease. The common bile duct cannot be identified. Normal color flow and\n waveforms are seen in the main portal vein, left portal vein, probable right\n portal vein, and left, middle, and right hepatic veins, as well as in the main\n hepatic artery.\n\n IMPRESSION: Limited study as described above. Gross patency of portal and\n hepatic veins and hepatic arteries.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-05-22 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1085474, "text": ", J. FA10 4:15 PM\n DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Evaluate hepatic vasculature and portal vein for thrombosis\n Admitting Diagnosis: POLYCYSTIC KIDNEY DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62F with polycystic liver s/p bilateral nephrectomy for polycystic kidney\n disease for pain now with elevated LFT's\n REASON FOR THIS EXAMINATION:\n Evaluate hepatic vasculature and portal vein for thrombosis and bile duct\n dilatation\n ______________________________________________________________________________\n PFI REPORT\n Limited examination due to polycystic liver disease replacing the liver with\n innumerable cysts. Gross patency of portal and hepatic veins, and hepatic\n arteries.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2119-08-27 00:00:00.000", "description": "Report", "row_id": 1621496, "text": "NURSING PROGRESS NOTE 0700-1900\n68 Y/O PRIMARILY SPANISH SPEAKING WF WITH H/O AFIB, CHF WITH EF OF 10%, CAD, DM2, S/P AKA, ESRD ON HD WHO INITIALLY PRESENTED TO THE MEDICAL SERVICE ON S/P MECHANICAL FALL. PT ADMITTED FOR PAIN MANAGEMENT AND WHILE ON FLOOR- NOTED TO BE HYPOTENSIVE AND FOUND TO HAVE GPC'S IN BLOOD CULTURES. TX TO MICU FOR FURTHER MANAGEMENT AND FOR PRESSOR INITIATION. PT HAS BEEN DOING WELL AND HAS CURRENTLY OFF OF PRESSORS FOR 24 HRS. (SINCE )\n\nNEURO: ALERT AND ORIENTED X 3. ABLE TO EXPRESS NEEDS WITHOUT DIFFICULTY. CONSTANTLY C/O PAIN WHICH IS RELIEVED WITH OXYCODONE. EXTREMELY ANXIOUS. AFEBRILE. PERRLA, 3/BRISK. NO SEIZURE ACTIBITY NOTED.\n\nRR: BBS= ESSENTIALLY CLEAR TO BIL. UPPER LOBES AND DIMINISHED TO BASES. SP02 > OR = TO 95%. CURRENTLY ON 1L 02 VIA NC- MOSTLY FOR PT'S COMFORT. BILATERAL CHEST EXPANSION NOTED. NON-PRODUCTIVE COUGH.\n\nCV: S1 AND S2 AS PER AUSCULTATION. AV PACED. HR 90-100'S WITH NO SIGNS OF ECOTPY NOTED. SBP > OR = TO 100. DENIES ANY CHEST PAIN. LT IJ CVL IS SECURE AND PATENT, CVP 8-10. HEPARIN INITIATED FOR KNOWN CLOT TO RT. SCL. TITRATING AS PER SLIDING SCALE. NOTED TO HAVE SOME OOZING AROUND LT IJ SITE. HEPARIN GTT INITIATED FOR RT SCL CLOT- VERIFIED VIA U/S TODAY. TITRATING AS PER SLIDING SCALE PROTOCOL.\n\nGI: ABD IS LARGE, OBESE, BS X 4 QUADRANTS. ABLE TO TOLERATE PO'S- NO C/O N,V,D. NO BM THIS SHIFT- REFUSING SUPPOSITORY ALTHOUGH PT HAD INITIALLY REQUESTED IT. ON PO REGIMEN. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. MINIMAL AMOUNTS OF AMBER URINE NOTED. HD PATIENT.\n\nINTEG: GROSSLY INTACT. NO SIGNS OF BREAKDOWN NOTED.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: HEPARIN GTT. CALL OUT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2119-08-28 00:00:00.000", "description": "Report", "row_id": 1621497, "text": "MICU 7 RN REPORT 1900-0700\n\n\n 68 YO spanish speaking fe w/ H/O multiple medical problem fell down from bed. In ED hypotensive to 80 received 500ml fluid bolus and received morphine and percocet for pain trauma work up done all was negative. Admitted to floor for pain management but again triggered hypotension to 70 received 750cc fluid bolus tx to MICU for further management. She was non resposive to fluid requiring pressors also treated w/ heparin for her A fib. Currently she is off pressors and still continuing on wt based heparin GTT.\n\nEVENT: Oxycodone PO for pain and respiratory treatment for wheezing.\n\nNEURO: Pt is alert and oriented x3. Moves extremities. received oxycodone PO for pain @ and 2400 w/ effect. Slept fairly needs lots of encouragement with turning.\n\nCV: HR in 80's paced, SBP 98-110. Heparin running @ 600 units/hr AM labs pending. Access LIJ TL and rt subclavian HD cath .\n\nRESP: LS coarse, Sats > 94%. Became wheezy around 2200 received nebs and cough med w/ effect.\n\nGI/GU: Abd soft, BS positive received bowel regimen but no BM in this shift. Foley draining amber urine.\n\nID: T max 98.1. Abx vancomycin on HD protocol.\n\nSOCIAL: Full code.\n\nPLAN: HD on T/Th/SAT. ? C/O. Resp treatments and pain meds as required. Check PTT and titrate heparin GTT.\n" }, { "category": "Radiology", "chartdate": "2119-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021197, "text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: dyspnea\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CHF with EF 10% with SOB and CP\n REASON FOR THIS EXAMINATION:\n dyspnea\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive failure with low EF and shortness of breath.\n\n FINDINGS: In comparison with the study of , there is no interval change.\n Moderate cardiomegaly is again seen with signs of mild overhydration. No\n acute pneumonia. The central venous access line and cardiac pacemaker remain\n in place.\n\n IMPRESSION: Little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-29 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1022599, "text": " 4:28 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: place tunnelled HD line\n Admitting Diagnosis: S/P FALL\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with esrd\n REASON FOR THIS EXAMINATION:\n place tunnelled HD line\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc FRI 10:14 PM\n Uncomplicated right IJ approach dual-lumen hemodialysis catheter placement;\n catheter ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old female with end-stage renal disease. Please place\n tunneled hemodialysis catheter line.\n\n COMPARISON: None available.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , with\n Dr. supervising.\n\n PROCEDURE: De hemodialysis catheter placement was performed on the right\n side via internal jugular approach. The patient was placed supine on the\n angiographic table and the right neck was prepped and draped in a standard\n sterile fashion. A preprocedure timeout was performed confirming the patient's\n name, medical record number, and date of birth, and procedure to be performed.\n\n Ultrasound was performed on the right neck and the right anterior internal\n jugular vein was identified, which appeared to be compressible. At this\n point, the right internal jugular vein was punctured, and a 0.018 guidewire\n was advanced through the needle into the SVC under fluoroscopic guidance. Hard\n copy ultrasound images were obtained before and after vascular access\n documenting vessel patency. The needle was exchanged for micropuncture\n sheath. At this point, attention was directed to the creation of a\n subcutaneous tunnel, and after using approximately 10 cc of 1% lidocaine with\n epinephrine, small incision was performed in the left upper chest and a\n subcutaneous tunnel was created with a blunt tunneling device, connecting the\n incision to the puncture site in the neck. The double-lumen dialysis catheter\n was tunneled through the subcutaneous tissue into the skin entry site into the\n neck.\n\n An Amplatz wire was advanced through the micropuncture sheath into the IVC\n under fluoroscopic guidance and the micropuncture sheath was then removed. The\n skin entry site was dilated over the Amplatz wire with 10 and 12 French\n dilators. A peel-away sheath was then advanced over the wire into the SVC\n under fluoroscopic guidance. The wire, inner dilator, and peel-away sheath\n were removed and the catheter was advanced through the peel-away sheath into\n (Over)\n\n 4:28 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: place tunnelled HD line\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the SVC. The peel-away sheath was then removed and the catheter was advanced\n into the right atrium. Both lumens of the catheter were then flushed,\n heplocked, and capped. The catheter was secured to the skin with 0 silk\n sutures. The puncture site of the neck was closed with 4-0 Prolene sutures.\n\n A sterile dressing was applied. Final fluoroscopic image of the chest\n demonstrated the tip of the catheter to be located in the right atrium. The\n patient tolerated the procedure well without immediate complications and the\n patient's hemodynamic parameters were monitored during the procedure.\n\n IMPRESSION: Uncomplicated placement of a tunneled double-lumen right IJ\n approach hemodialysis catheter. The catheter is ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-29 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1022600, "text": ", B. MED CC7A 4:28 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: place tunnelled HD line\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with esrd\n REASON FOR THIS EXAMINATION:\n place tunnelled HD line\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated right IJ approach dual-lumen hemodialysis catheter placement;\n catheter ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021629, "text": " 3:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening edema or interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with bacteremia and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for worsening edema or interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: \n\n FINDINGS: As compared to the previous examination, the markings of the\n interstitial space have increased in number and extent. This suggests\n increased interstitial fluid retention. Suspicion of a small right-sided\n pleural effusion. The size of the cardiac silhouette is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1022160, "text": " 8:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement; eval for ptx\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with bacteremia s/p left IJ placement\n REASON FOR THIS EXAMINATION:\n eval for line placement; eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 68-year-old woman with bacteremia status post left IJ line\n placement. Evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a right-sided pleural effusion which is stable. There is mild\n prominence of pulmonary vascular markings also stable. There is unchanged\n cardiomegaly. There has been removal of the right-sided central venous\n catheter. No pneumothoraces are identified. There is a new left-sided\n catheter whose distal tip is at the cavoatrial junction.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-27 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1022245, "text": " 12:43 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: EVAL FOR DVT, ESPECIALLY IJ, CLOT SEEN ON PREV US PAIN\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p R tunneled line removal due to bacteremia now with ?DVT\n in IJ\n REASON FOR THIS EXAMINATION:\n eval for DVT in upper ext, especially IJ\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 2:13 PM\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND\n\n Partially occlusive thrombus, involving right internal jugular vein, without\n extension into the subclavian.\n ______________________________________________________________________________\n FINAL REPORT\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND\n\n INDICATION: 68-year-old woman status post right internal line removal\n secondary to bacteremia, with DVT.\n\n COMPARISON: Not available.\n\n FINDINGS: There is a partially occlusive thrombus in the right internal\n jugular vein. The right subclavian, axillary, brachial veins are patent,\n without evidence of thrombosis.\n\n IMPRESSION: Partially occlusive thrombus in the right internal jugular vein.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-27 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1022246, "text": ", P. MED MICU-7 12:43 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: EVAL FOR DVT, ESPECIALLY IJ, CLOT SEEN ON PREV US PAIN\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p R tunneled line removal due to bacteremia now with ?DVT\n in IJ\n REASON FOR THIS EXAMINATION:\n eval for DVT in upper ext, especially IJ\n ______________________________________________________________________________\n PFI REPORT\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND\n\n Partially occlusive thrombus, involving right internal jugular vein, without\n extension into the subclavian.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021959, "text": " 12:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid status, pna, interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with esrd, hypotension, chf, incr 02 req. ssob\n REASON FOR THIS EXAMINATION:\n eval for fluid status, pna, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female with end-stage renal disease, hypotension and\n CHF.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: A right dual lumen internal jugular central venous\n line and left pacemaker leads are in unchanged position. Moderate cardiac\n enlargement is stable. Increased interstitial markings consistent with mild\n interstitial edema are unchanged, however, a small right-sided pleural\n effusion has mildly increased in size.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-26 00:00:00.000", "description": "REMOVE TUNNELED CENTRAL W/O PORT", "row_id": 1022116, "text": " 2:01 PM\n DIALYSIS REMOVE Clip # \n Reason: please remove tunnelled line secondary to bacteremia\n Admitting Diagnosis: S/P FALL\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with peristent bacteremia despite therapy with right sided\n tunneled dialysis catheter\n REASON FOR THIS EXAMINATION:\n please remove tunnelled line secondary to bacteremia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. .\n Dr. , the Attedning Radiologist, was present and supervised the entire\n procedure.\n\n PROCEDURE: Under sterile conditions and using 1% lidocaine for local\n anesthesia, the tunneled 14.5-French dual lumen hemodialysis catheter was\n removed from the right internal jugular vein. Manual pressure was held over\n the venous puncture site and at the catheter entrance site until hemostasis\n was achieved. The tip of the catheter was sent for culture. A dry sterile\n dressing was applied.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful removal of a tunneled 14.5-French hemodialysis\n catheter from the right internal jugular vein without incident.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-24 00:00:00.000", "description": "Report", "row_id": 1621489, "text": "nursing progress notes from 0700 to 1900 hrs.\nSignificant events : Hemodialysis , 3 lit fluid out.\n Levophed titrating down.\nNeuro: Patient alert, oriented X3. Moves upper & rt lower extremities.left leg amputated. C/O pain at rt foot. Oxycodone 5 mg at frequent interval given. Denies any relief from pain medication. Remains demanding . Pupils equally reactive. Mostly spanish speaking.\n\nResp : Satting at high 90's with nasal cannula 2 lit/min. Lungs are clear at upper lobes , diminished at bases bilaterally. RR 24-34 bpm. C/O SOB, Upper airway wheezing noted. AtroventX1 & albuterol nebX2 given on prn basis. Coughing frequently but not productive, Mucinex & guaifenasin given. patient C/O did not help much.\n\nC/V : AV paced, HR 80-100's. SBP 85-130's. Levo titrated down. Goal SBP 85 mm of hg. hemodialysis done, 3 L fluid out. Maintained BP above 100's throughout the hemodialysis. Vamcomycin 500 mg IV given as per order after hemodialysis ( as vanc random 12.8). Rt femoral veinous line in place, dressing changed. CVP 20-22 mm of hg. hemodialysis cath in place at rt subclavian. Next hemodialysis on saturday. Repeat PTT >150, notified MD.\n\nGI/GU : Abdomen obese, bowel sound audible at all quadrants. Refused lunch. Hemodialysis done 3 L fluid out. urine output 80 ml /12 hrs, amber & sedimented. F/U with renal. No BM at this shift.\n\nSkin : intact, no integrity noted.\n\nED : FSBS, coverage with insulin sliding scale.'\n\nID : Stool to be sent for C-diff. Afebrile. vancomycin 500 mg IV given with hemodialysis. Blood culture X1 sent today.\n\nDispo/plan : Full code. Daughter called up, updated the status. demands for more pain medication. Explained by RN & MD & daughter. F/U with social worker ?hospice care. Social work notified as patient's daughter wants to talk to S/W. ? may require CVVHD in future. Plan to wean off levo as tolerated. Will cont the rest.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-25 00:00:00.000", "description": "Report", "row_id": 1621490, "text": "1900-0700 rn notes micu\n\nneuro: no changes in neuro status. pt A/Ox3, cont c/o of back and LLE pain, given Oxycodone around the clock.Lidocain patch apllied.given Ambien with some response.\n\nresp: NC 2L,sat 96-98%, LS clear/coarse dim at bases, pt c/o of SOB after reposition, given nebs treat with some effect.cont to cough, given guaifenasin.\n\ncv: HR 80's, AV paced, rare PVC's. cont levophed, BP 87-108's, after levophed was stopped BP dropped to high 70's, Levophed restart, currently 0.028mcg/kg/min.last PTT 40,INR 1.7, given Coumadin. afebrile.\n\nendo: BS 144, given Glargin 12units\n\ngi/gu: PT ESRD on HD, but making some urine. ABD soft, BS+, no stool.\n\nsocial: full code, pt's daughter updated by RN\n\nplan: cont monitoring resp/cardio status\n wean levophed to keep SBP 85\n next HD on saturday.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-25 00:00:00.000", "description": "Report", "row_id": 1621491, "text": "Nursing progress notes form 0700 to 1900 hrs.\n\nNeuro : Alert, oriented X3. left leg BKA, movin. C/O pain at rt thorax, legs. PO oxycodone given q 4 hrly with some effect. Pupils reactive equally. she is demanding & attention -seeking, mostly spanish speaking.\n\nResp : Satting at 89 to 95 % on room air. Oxygen off since 0830 hrs. Lungs are coarse, slight exp wheezing noted bilaterally. Mostly upper airway wheezing ausculteed. C/O difficulty in breathing , but nothing obvious noted other than upper airway wheezing. Mucinex PO , albuterol, atrovent given on prn basisround the clock.CXR done today.\n\nC/V : AV paced, PVC rare to occasional. Received on levophed, off since 0830 hrs, tolerating well so far. SBP >85 mm of hg. Goal to keep SBP >85 mm of hg. If BP drop drops, may resume levo & may need A-line placement. Rt femoral line in place & patent. CVP 18-21 mm of hg. NO edema noted. Hemodialysis cath in place at rt S/C, patent, WNL.\n\nGI/GU : Good appetite. On renal diet. audible bowel sounds X4, abdomen soft distended. Indwelling urinary cath in place, minimal urine output. Hemodialysis started at 1545 hrs, goal negative 3 kg. f/U with renal.\n\nID: afebrile, On contact precautions. Stool need to be sent for C-diff.\n\nEndo : FSBS, coverage per sliding scale.\n\nSkin : intact.\n\nID : Afebrile.\n\nDispo/Plan : Full code. Daughter visited & updated the status. Hemodialysis going on, goal : neg 3 kg. Scheduled hemodialysis on tues/thurs/sat. Hemodialysis wire will be changed by renal fellow on monday. Will continue to monitor her resp status & BP.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-25 00:00:00.000", "description": "Report", "row_id": 1621492, "text": "Additional nurses notes.\nHemodialysis done. 3 L fluid ultrafiltrated. Maintained SBP 90-110 throughout the hemodialysis. Levo off.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-26 00:00:00.000", "description": "Report", "row_id": 1621493, "text": "1900-0700 rn notes micu\n\nneuro: neuro status intact, A/Ox3, asking for Oxycodone q4hr for pain in LLE with some response, moaning nad screaming withturning, resistant to be turn often.\n\nresp: NC 2L, sat 100%, given nebs treatment for SOB after reposotion with some response.LS coarse dim at bases to clear. given Musinex for cough.\n\ncv: HR 80's, AV paced, occass , pt was off Levophed untill 0300 when pt dropped BP to 70's while sleeping, goal SBP >=85.given Coumadin PO.morning labs pending.\n\ngi/gu: pt On HD, but void minimal urine amber with sone . ABD soft, BS+, no stool start bowel regiment. please send sample for c diff.\n\nskin: intact\naccess: femoral line. RSC HD.\n\nsocial: full code, no conatct from family\n\nplan: monitoring resp/cardio stayus\n wean levo\n chnages over wire HD cat on monady in IR\n" }, { "category": "Nursing/other", "chartdate": "2119-08-26 00:00:00.000", "description": "Report", "row_id": 1621494, "text": "0700-1900\nneuro: AAOx3, follows commands, moving all extremites\n\ncv: hr av pcd, no ectopy, sbp 88-119, map 60-80, levo gtt weaned to off, goal map >/= 55\n\nresp: on 2 l np, bs+ all lobes, course, decreased to bases, neb tx x 2 for wheezing, dex-guaifenesin x 2 for cough, sat 100, no resp distress noted\n\ngi: renal diet tol well, no N/V or stool, po colace\n\ngu: foley patent, clear amber urine, minimal uo, HD today x 31/2 hrs, 1.5 liters removed, iv vanco given by HD nurse, bld cultures sent off HD cath by HD nurse, HD cath dc'd by HO & tip sent for culture, + bld cultures from with gm + cocci(bld culture from R fem cl), pt to have new HD cath placed in IR on Monday\n\nother: c/o L hip pain x 1 & medicated with oxycodone x 1 with relief, no family contact today, pt to have R IJ inserted by HO & to dc R fem cl\n\nplan: line placement, levo for map < 55\n" }, { "category": "Nursing/other", "chartdate": "2119-08-27 00:00:00.000", "description": "Report", "row_id": 1621495, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS NKDA.\n\nPT. REMAINS ON CONTACT PRECAUTIONS TO R/O CDIFF. PT. HAS ALSO HAD MRSE IN THE PAST.\n\nPT. REMAINS A/A/O AND HAS COMPLIANED OF NECK/STUB/AND BACK PAIN THROUGHOUT THIS SHIFT REQUIRING OXYCODONE 5MG PO Q4HRS. PT. HAS ALSO DEMANDED HER PRN DEXTROMETHORPHAN COUGH MEDICINE Q6HRS ALSO WELL. PT. HAS REMAINED AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS REMAINED AV PACED WITH NO NOTED ECTOPY, 90'S. B/P HAS REMAINED UNSUPPORTED SINCE 1500 YESTERDAY. B/P THIS SHIFT HAS RANGED, 92-123/50-60'S. CVP HAS RANGED 17-24.\n\nPT. HAS REQUESTED MULTIPLE ALBUTEROL NEBS THROUGHOUT THIS SHIFT. PT. HAS BEEN CLEAR MID TO UPPER LOBES WHILE DIMINISHED BIBASILAR. RESP RATE IS CONTROLLED AND O2 SATS REMAIN >98% THROUGHOUT THIS SHIFT.\n\nPT. REMAINS ON A RENAL DIET WHICH SHE TOLERATES WELL. ABD. REMAINS BENIGN IN ASSESSMENT. BOWEL SOUNDS ARE AUDUBLE X4 QUADRANTS, NO STOOL NOTED THIS SHIFT. FOLEY CATHETER REMAINS INTACT, WHILE DRAINING AMBER SEDIMENT URINE IN SCANT AMT'S. PT. HAD H.D. YESTERDAY FOR 1.5 LITERS REMOVED.\n\nPT. HAS NEW LEFT I.J TLC PLACED LAST EVENING. THIS SITE CONTINUES TO OOZE SMALL AMT OF BLOOD AT INSERTION SITE. ALL PORTS REMAIN INTACT AND PATENT. BOTH PT'S RIGHT FEMORAL LINE AND DIALYSIS LINE WERE D/C'D YESTERDAY FOLLOWING BLOOD CULTURE RESULTS OF GRAM + COCCI. PT. IS SCHEDULED FOR I.R. ON MONDAY TO HAVE A NEW DIALYSIS LINE PLACED.\nOTHERWISE, SKIN REMAINS UNREMARKABLE.\n\nPLAN IS TO MONITOR AND SUPPORT B/P MAP <55. PLAN FOR NEW H.D. LINE MONDAY. PT. IS ALSO SCHEDULED FOR UPPER EXTREMITIES U/S PENDING POTENTIAL CLOT NOTED DURING THE ATTEMPT OF THE TLC LAST EVENING.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-28 00:00:00.000", "description": "Report", "row_id": 1621498, "text": "RESPIRATORY CARE:\n\nFollowing pt for PRN Albuterol and Atrovent neb rx's. Pt had 2 episodes of increased SOB and wheezing overnight, requiring combined nebs. BS's improved with bronchodilators. Cough strong, non productive. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-28 00:00:00.000", "description": "Report", "row_id": 1621499, "text": "pmicu nursing progress 7a-3p\nreview of systems\nCV-vs have been stable.hr is a-v paced. completely off levo x 24 hours.\n\nRESP-wearing o2 2l for comfort. o2 sats 95-100%. receiving inhalers as per RT for mild wheezing, comfort.\n\nGI-abd soft with positive bowel sounds. no stool today.eating well.\n\nF/E-has had minimal urinary output. next HD planned for tommorrow.mild peripheral edema noted.please see labs in carevue- BUN=24 and creat 2.5.\n\nHEME-had heparin infusing at 450 u/hr. was turned off at 7:30 am for ? tunnel cath placement.procedure will be tommorrow and so heparin resumed at 12:30 pm at same dose.coumadin on hold.\n\nID-afebrile. WBC 9.5. a surveillence blood cx was sent.receieives vanco with HD. micro report with 2/2 bottles blood cx positive for gm pos cocci- not speciated yet\n\nNeuro- a=o x 3. cooperative.requesting pain meds ~ q 4 hrs.\n\nIV ACCESS- has a L IJ- dressing changed.also a R subclavian HD catheter.\n\nSOCIAL-speaking with daughter on phone\n\na-stable, called out to floor.still a little anxious.\n\nP-updated call out- continue with neb tx. tunnel catheter tommorrow then HD as planned.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-21 00:00:00.000", "description": "Report", "row_id": 1621483, "text": "1900-2100 CV-ICU\n\nPt A&O x3. Appropriate behavior. Spanish & English speaking. AV-paced\nfrom internal pacer. Bp 88-54. no gtts. 2lnc=100% lsc. abd soft. + bs. foley catheter in place with no drg. c/o rt rib & hip pain. 5mg oxycodone x1. Ultrasound guided rt femoral TLC placed by MICU MD.\n\nReport called to MICU 7 and pr transferrred to rm # 783 @ 2130.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-22 00:00:00.000", "description": "Report", "row_id": 1621484, "text": "NPN 7p-7a\nIn brief, pt is a 68y/o spanish speaking womanwith h/o afib on Coumadin, CHF with EF 10%,CAD,DM2,s/p L AKA,ESRD on HD who initially presented to medicine service s/p mechanical fall. CXR, CT of head, C-spine, and abd/pelvis all negative. Pt was admitted for pain management fall. Pt triggered upon arrival to the floor for hypotension and improved with fluids. On , pt was found to have GPCs in BCs and started on vanco. In am , pt was again hypotensive but not responsive to fluids. Pt admitted to CVICU under MICU Green service. Further fluids given, difficult line placement requiring Right femoral line. Pt transfered to MICU overnight. 500cc fluid bolus given with poor effect. NBP 60s, levophed started. Aline has not been placed as of yet.\n\nNEURO: Pt has been alert and oriented x3. pleasant and cooperative with care. pt mostly spanish speaking but can communicate in some English and can make her needs known. Pt has c/o right rib pain, lidocaine patch in place. Pt ordered prn Oxycodone, but has not received any since prior to transfer. Pt has slept for several hours over night and appears comfortable.\n\nCV: HR 70av-paced. BP 80s-100s/50s, MAP>60 and supported by Levophed gtt. CVP was tranduced of femoral line to attempt at following trends. Numbers are not accurate. Pt has dopplerable pulses on right PT/DP.\n\nRESP: Sats 98-100% on 2.0L NC. Pt did c/o SOB x1 and given alb neb with good effect. LS clear upper with bibasilar crackles. RR 15-20. pt has dry nonproductive cough.\n\nGI/GU: ABD is soft, obese, +BS. No stool this shift. Pt tolerating diet. Pt did have Strongyloides (parasite) grow out of stool. Pt received Ivermectin x1 for this. Pt is oliguric, on HD Tues/Thurs/Sat.\n\nID: Currently covered on Flagyl and vanco by level. Further cultures pending. Pt has been afebrile.\n\nSOCIAL: Pt's daughter called and was updated.\n\nPLAN: Wean levophed as tolerated.\n ? CVVHD vs. HD today, f/u with renal reqs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-22 00:00:00.000", "description": "Report", "row_id": 1621485, "text": "Nursing Note: 0700-1900\nNEURO: Alert/oriented X 3; able to make needs known. C/O chronic pain at right torso; receiving Oxycodone with some effect. MAE.\n\nRESP: LS essentially clear but requests albuterol nebs consistently. Sats maintained at or near 100% on 2L n/c.\n\nC/V: HR 80s, paced; no ectopy. Able to wean Levophed gtt to minimal dose 0.03mcg/kg/min butleft on during HD. Plan is to run even today. BP at baseline 90s-100s so HD done today. Received 250cc bolus with some effect.\n\nID: Flagyl/vanco for MRSE bacteremia; 6 of 6 bottles positive. Ivermectin dosing for stool parasite; next dose to be administered next week. Afebrile. Surveilance cx sent from HD line. Last vanco level 17; received 500mg IV during HD.\n\nGI/GU: Tolerating Renal diet well. No BM. Minimal u/o ~ 10cc/hr.\n\nSKIN: Intact.\n\nDISPO/PLAN: Full code; contact precautions; HD on sched; spoke with dtr by phone today who indicated that overall plan was to investigate eventual Hospice support; social work consulted.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-23 00:00:00.000", "description": "Report", "row_id": 1621486, "text": "NPN 7p-7a\nPt is a 68y/o with h/o AF, ischemic cardiomyopathy with EF 10%, CAD, DM2, ESRD on HD s/p L BKA admitted after mechanical fall. Pt was transfered from the floor for hyptension initially responsive to fluids, now with MRSE bacteremia and on Levophed.\n\nNEURO: Pt is mostly spanish speaking, can speak some English and make her needs known. Pt c/o pain consistently with turning and movement and given prn Oxycodone with good effect. Pt given 25mg Trazadone for sleep per her request.\n\nCV: HR 70s-80s AV paced. Levophed was weaned off for several hours, but then dropped BP to 60s. Levophed was turned back on titrating to maintain MAP>60. Pt has dopplerable pulses on RLE. Coumadin restarted.\n\nRESP: Sats 98-100% on 2.0L. Pt c/o cough, given Guafenesin x1 with good effect. Pt also persistently asking for neb treatments. Pt does not sound wheezy or tight, ? if this is anxiety related. LS clear, diminished bases. RR 15-20.\n\nGI/GU: ABd is soft, obese, +BS. Pt tolerating /Renal diet well, good appetite. Pt is oliguric, s/p HD yesterday with 2.0L fluid removed.\n\nID: Pt has been afebrile. Covered on Vanco and Flagyl. BCs have grown MRSE.\n\nPLAN: Wean levophed as tolerated.\n Pain management.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-21 00:00:00.000", "description": "Report", "row_id": 1621481, "text": "Admitted from 2 for hypotension, SBP 70's after 750 ml fluid bolus, A&O x3 all the time, admitted to CVICU for closer monitoring for BP\n\nNeuro: Spanish speaking, speaks some English, MAE's, following commands, PERRLA 3 mm brisk, A&O x3\n\nCV: Afebrile; AV paced by perm pacer, no ectopy, last INR 3.5, received 2 units FFP for line placement; SBP 60's-100's, SBP slowly trending up as the day goes, attempted to place CVL by MICU team, will re-evaluate per team since pt improving, want 2nd PIV in, if not, may put in CVL\n\nResp: Lung sound clear, 2L NC 100%, non-productive cough\n\nGI: Abd soft, tolerating diet, loaded with bowel regimen last night floor RN, loose BM x5 overnight, pt c/o cannot move bowel, explained she went 5 times last night and does not need further bowel regimen yet, stool grew out + parasite stronglyloides stercoralis, MICU team awared, 1 dose of ivermectin given\n\nGU: HD pt, foley placed per MICU service requested, urine cx sent, minimal amber clear urine\n\nInteg: intact\n\nID: Started on flagyl, awaiting stool for c-diff\n\nPain: c/o pain on side of chest with activity, team awared, extra 0.5mg IV morphine given, PO oxycodone PRN\n\nSocial: Daughter called, MICU team talked to daughter & updated\n\nPlan: monitor BP; pain mangement; social work consult; get 2nd PIV, if not paged MICU team for plan\n" }, { "category": "Nursing/other", "chartdate": "2119-08-21 00:00:00.000", "description": "Report", "row_id": 1621482, "text": "PIV infiltrated @ 1830, MICU team awared, CVL palcement @ bedside, awared of hypotension, 500 ml NS bolus ordered, not able to give d/t infiltrated IV. Will have surface ECHO to evaluate heart fxn tonight\n" }, { "category": "Nursing/other", "chartdate": "2119-08-23 00:00:00.000", "description": "Report", "row_id": 1621487, "text": "Nursing progress notes from 0700 to 1900 hrs.\nNeuro: Alert, oriented X3. MAE\"S.Mostly spanish speaking, speaks few english. C/O generalised pain, pain with turning and movement, receiving oxycodone q 4 hrly with therapeutic effect. Pupils are equal & reactive.\n\nResp: On 2 L nasal cannula , satting at mid 90's. RR 20-30's/min. Lunfs are clear at upper lobes bilaterally & diminished at bases bilaterally. Asks for cough meds & nebs frequently. Albuterol given on prn basis. No signs of labour breathing noted.\n\nCV :AV paced with multiple frequent PVC\"S. HR 80-90's. SBP 80-100's (NIBP). On Levo gtt @ 0.060 mcg/kg/hr, goal SBP 85 mm of hg. Weaning off levo. NS 250 ml X1 bolus given for hypotensive episode with good therapeutic effect. Hemodialysis . Vancomycin random level to be checked at AM prior to next due dose. On coumadin. Multiple lumen @ rt femoral in situ, all lumens are patent. CVP 8-10 mm of hg. Lido patch @ left amputated leg (BKA).\n\nGI/GU : Indwelling foley cath is in place, draining amber sedimented urine. urine output minimal. Patient on renal diet, good appetite. Bowel sounds audible at all quadrants.\n\nID : Blodd culture sent X1 sent. Stool for c. diff to be sent. Afebrile.\n\nSkin : Intact , No imapiared integrity noted.\n\nEndo : On insulin sliding scale & fixed dose. Will cont on synthroid for hypothyroidism.\n\nPlan/Dispo : Full code. daughter visiting her, updated the status. Updated social worker regarding ? hospice care. Plan to Wean off levophed if tolerated, goal SBP 85 mm of hg.. Hemodialysis , recheck vancomycin random level prior to previous dose.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-24 00:00:00.000", "description": "Report", "row_id": 1621488, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS NKDA.\n\nPT. REMAINS ON CONTACT PRECAUTIONS TO R/O CDIFF, STOOL SPECIMENS STILL NEEDED.\n\nPT. REMAINS A/A/O AND IS QUITE DEMANDING WITH ALL HER CARE ISSUES. PT. C/O PERIODIC PAIN IN LEFT LEG REQUIRING HER OXYCODONE Q4-6HRS. WITH NOTED RELIEF. PT. HAS BEEN AFEBRILE.\n\nPT. HAS REMAINED AV PACED WITH OCCASIONAL PVC'S RATE 70-90'S. B/P REMAINS STABLE RANGING 99-117/40-60'S WHILE BEING SUPPORTED ON LEVOPHED GTT AT 0.06MCG/KG/MIN. EVERY ATTEMPTS MADE TO WEAN, PT'S B/P DROPPED. CVP RANGING 17-22.\n\nPT. LUNGS REMAIN CLEAR/DIM, WITH RESP RATE CONTROLLED AND O2 SATS REMAIN>95% WHILE ON 4L/MIN VIA NASAL CANNULA. WHEN OFF N/C PT. DID DESAT TO 89%. PT. RECEIVED TWO ALBUTEROL NEUBS PRN. PT. CONTINUES TO EXHIBIT A NON PRODUCTIVE COUGH.\n\nPT. CONTINUES ON HER SAME DIET. BLOOD SUGARS ARE STABLE. ABD. REMAINS BENIGN WITH NO STOOL NOTED THIS SHIFT. BOWEL SOUNDS EASILY AUDIBLE.\nFOLEY CATHETER REMAINS IN PLACE DRAINING SCANT AMT'S OF SEDIMENT AMBER URINE.\n\nSKIN REMAINS UNREMARKABLE, ALL LINES REMAIN INTACT SECURED, AND FUNCTIONING WELL.\n\nPLAN IS FOR POSSIBLE HOSPICE WORKUP WITH ASSISTANCE OF SOCIAL WORK AND PT'S DAUGHTER. OTHERWISE, CONTINUE TO WEAN LEVOPHED WHEN ABLE TO.\n" }, { "category": "Radiology", "chartdate": "2119-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020951, "text": " 3:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for rib fx, pulmonary edema, infection, overload\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p fall, with right-sided pain, CHF, CAD, and wheezing\n REASON FOR THIS EXAMINATION:\n Eval for rib fx, pulmonary edema, infection, overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Search for pulmonary edema or infection.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Moderate cardiomegaly, signs of moderate overhydration. No focal\n parenchymal opacity suggestive of pneumonia, double-lumen central venous\n access line, cardiac pacemaker in situ.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1020823, "text": " 12:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for right sided chest pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with s/p fall onto right chest, now with pain\n REASON FOR THIS EXAMINATION:\n eval for right sided chest pain\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old female status post fall onto right chest, now with pain\n on the right.\n\n COMPARISON: Chest radiographs from through .\n\n PORTABLE CHEST RADIOGRAPH, FRONTAL SEMI-UPRIGHT VIEW: Per technologist's\n report, patient was unable to follow instructions well. The left chest wall\n and left lateral sulcus are excluded on the current study. Left-sided\n pacemaker/AICD, median sternotomy wires, and left IJ dual-lumen large bore\n dialysis catheter are all in unchanged positions. Apparent discontinuity\n along the uppermost median sternotomy wire is unchanged.\n\n The patient is status post CABG. Cardiomegaly is unchanged. Upper zone\n vascular redistribution, mild interstitial edema, and small right pleural\n effusion are grossly unchanged. Lung volumes are slightly decreased compared\n to the most recent prior study. There is no evidence of pneumothorax. No\n displaced rib fractures are seen on the right.\n\n IMPRESSION: Limited exam is grossly not changed from , however, if\n there remains concern for acute intrathoracic process or for rib fractures,\n repeat is requested with optimized technique.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1020835, "text": " 1:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Reason for exam should also state head and neck pain after fall. This\n information was available at the time of exam but omitted from the original\n report.\n\n\n 1:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman on coumadin s/p fall\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 3:13 PM\n no acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female on Coumadin, status post fall. Please\n evaluate for bleed.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no evidence of mass,\n mass effect, edema, or acute vascular territorial infarction. Ventricles and\n sulci are unchanged in size and configuration. There is no fracture.\n Visualized paranasal sinuses are normally aerated. Extensive vascular\n calcifications within the subcutaneous tissues are unchanged.\n\n IMPRESSION: No acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1020836, "text": " 1:48 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman on coumadin s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 3:22 PM\n no cervical spine fx or malalignment, though slightly limited by pt motion\n\n probable small tracheal diverticulum at level of C7.\n\n irregular soft tissue density material at level of C6 most likely represents\n thickened secretions or mucous.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female taking Coumadin, status post fall. Please\n evaluate for fracture.\n\n COMPARISON: None available.\n\n TECHNIQUE: Non-contrast CT of the cervical spine with multiplanar\n reformations.\n\n FINDINGS: Evaluation is slightly limited due to patient motion, despite\n repeated attempts to scan.\n\n There is no cervical spine fracture or malalignment. Vertebral body and\n intervertebral disc space heights are preserved. Prevertebral and paraspinal\n soft tissues are not enlarged. Visualized outline of the thecal sac appears\n unremarkable, but please note that CT is unable to provide intrathecal detail\n comparable to MRI.\n\n Incidental note is made of probable small tracheal diverticulum at the level\n of C7, arising off the posterolateral aspect of the trachea. Just superior to\n this, at the level of C6, there is asymmetric soft tissue within the dependent\n portions of the trachea, most probably representing thickened secretions or\n mucus.\n\n Right internal jugular double-lumen central venous catheter is seen in place.\n Incidental note also made of prominent atherosclerotic calcification in the\n bilateral carotid bifurcations.\n\n IMPRESSION:\n\n 1. No definite cervical spine fracture or malalignment, though evaluation is\n slightly limited by patient motion.\n\n 2. Likely small tracheal diverticulum at the level of C7.\n\n (Over)\n\n 1:48 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Asymmetric soft tissue density in dependent portions of the trachea at the\n level of C6. Dedicated CT trachea protocol could be performed to further\n evaluate this area (as well as the diverticulum), if clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1020838, "text": " 2:31 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o tramatic organ injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fall, abd and back pain following\n REASON FOR THIS EXAMINATION:\n r/o tramatic organ injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 3:50 PM\n no acute traumatic injury.\n\n moderate simple right pleural effusion.\n trace simple ascites.\n\n marked vascular calcification.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female with fall, and abdominal and back pain\n following. Please evaluate for traumatic injury.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial imaging of the abdomen and pelvis was\n performed following administration of intravenous contrast. No oral contrast\n was administered. Multiplanar reformatted images were obtained and reviewed.\n\n CT ABDOMEN: Moderate-sized simple right pleural effusion is noted, with mild\n adjacent compressive atelectasis. There is mild left basilar atelectasis as\n well, and a trace amount of left pleural fluid. Double-lumen hemodialysis\n catheter tip is seen in the right atrium. Three intracardiac leads from a\n pacemaker/ICD device are also noted. There has been prior median sternotomy\n and CABG.\n\n There is trace ascites around the liver, which is otherwise unremarkable.\n There is no biliary ductal dilatation or ascites. The gallbladder is not\n visualized, presumably surgically absent. Pancreas, spleen, and adrenal\n glands are unremarkable. Stomach and intra-abdominal loops of bowel are\n unremarkable, allowing for limitation of no oral contrast opacification. There\n is no free air, or abnormal intra-abdominal lymphadenopathy. Kidneys enhance\n and excrete contrast symmetrically, but are atrophic bilaterally, consistent\n with patient's known end-stage renal disease on hemodialysis. There are\n extensive vascular calcifications throughout, most prominent in the small\n vessels.\n\n CT PELVIS: Pelvic loops of large and small bowel are unremarkable. Urinary\n bladder, uterus, and adnexa are unremarkable. There is a small amount of free\n pelvic fluid. There is no abnormal pelvic or inguinal lymphadenopathy.\n\n There is no suspicious osseous lesion. Mild multilevel thoracolumbar spine\n degenerative changes noted, with vacuum phenomenon and disc space narrowing at\n multiple levels.\n (Over)\n\n 2:31 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o tramatic organ injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. No acute traumatic injury in the abdomen or pelvis.\n\n 2. Moderate-sized simple right pleural effusion and adjacent compressive\n atelectasis.\n\n 3. Trace ascites.\n\n 4. Extensive vascular calcification.\n\n\n" }, { "category": "Echo", "chartdate": "2119-08-22 00:00:00.000", "description": "Report", "row_id": 85079, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 64\nWeight (lb): 160\nBSA (m2): 1.78 m2\nBP (mm Hg): 85/57\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:40\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 report of the prior study (images not\navailable) of .\n\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. Normal IVC diameter (<2.1cm) with\n35-50% decrease during respiration (estimated RAP (0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. Transmitral Doppler and TVI c/w Grade III/IV (severe)\nLV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\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 masses or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Moderate thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets.\nPhysiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n0-10mmHg. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis (LVEF = 15 %). Transmitral Doppler and tissue velocity\nimaging are consistent with Grade III/IV (severe) LV diastolic dysfunction.\nRight ventricular chamber size is normal. with normal free wall contractility.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. No masses or vegetations are seen on the mitral\nvalve, but cannot be fully excluded due to suboptimal image quality. There is\nmoderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is moderate pulmonary artery systolic hypertension. The pulmonic valve\nleaflets are thickened. There is no pericardial effusion.\n\nIMPRESSION: Mild ventricular hypertrophy with severe global systolic\ndysfunction and severe diastolic dysfunction. No echocardiographic evidence of\nendocarditis. Mild mitral regurgitation. Moderate pulmonary hypertension.\n\nCompared to prior report (), the severity of pulmonary hypertension has\ndecreased. The findings are otherwise similar.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1022730, "text": " 1:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for tracheal mass, diverticulum, which could explai\n Admitting Diagnosis: S/P FALL\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with ESRD, EF 20%, CABG, c/o stridor and constant c/o\n difficulty breathing with 100% sats, on c-spin comment of mass in trachea\n likely related to plug\n REASON FOR THIS EXAMINATION:\n evaluate for tracheal mass, diverticulum, which could explain stridor and\n c/o dyspnea\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb WED 8:09 PM\n Moderate pulmonary edema with interstitial and alveolar edema as well as\n moderate-sized right pleural effusion. No evidence of pulmonary embolism or\n tracheobronchomalacia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old with end-stage renal disease, CABG, and stridor.\n Evaluate for pulmonary embolism or tracheobronchomalacia.\n\n COMPARISON: Chest radiograph .\n\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained during\n inspiration and dynamic expiration using a benign CT trachea protocol. 100 cc\n of IV Optiray contrast was administered during inspiration using a non-gated\n CTA protocol. Coronal, sagittal, and multiple oblique MIP reformats were\n displayed.\n\n CTA OF THE CHEST: There is no evidence of pulmonary embolism or aortic\n dissection. The main pulmonary artery is prominent, indicative of pulmonary\n artery hypertension. The heart is markedly enlarged. Biventricular pacemaker\n is in place. Right internal jugular catheter terminates in the right atrium,\n while the left internal jugular catheter terminates in the mid SVC. There is\n confluent bilateral hilar and mediastinal lymphadenopathy, likely reactive to\n the pulmonary process.\n\n Moderate nonhemorrhagic right pleural effusion layers posteriorly with\n significant atelectasis of the right lower lobe. There is also moderate right\n upper lobe interstitial edema with interlobular septal thickening and ground\n glass-like opacification of the right lung suggesting alveolar edema. There is\n milder septal thickening within the left upper lobe, likely due to patient\n positioning. The trachea is of normal caliber during inspiration and dynamic\n expiration with no evidence of tracheobronchomalacia.\n\n There are no bone findings of malignancy.\n\n IMPRESSION:\n 1. Moderate cardiac decompensation as evidenced by interstitial and alveolar\n edema, moderate-sized right pleural effusion, and cardiomegaly. No acute\n (Over)\n\n 1:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for tracheal mass, diverticulum, which could explai\n Admitting Diagnosis: S/P FALL\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consolidative process.\n 2. No evidence of tracheobronchomalacia.\n 3. No evidence of pulmonary embolism.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1022731, "text": ", J. MED CC7A 1:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for tracheal mass, diverticulum, which could explai\n Admitting Diagnosis: S/P FALL\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with ESRD, EF 20%, CABG, c/o stridor and constant c/o\n difficulty breathing with 100% sats, on c-spin comment of mass in trachea\n likely related to plug\n REASON FOR THIS EXAMINATION:\n evaluate for tracheal mass, diverticulum, which could explain stridor and\n c/o dyspnea\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Moderate pulmonary edema with interstitial and alveolar edema as well as\n moderate-sized right pleural effusion. No evidence of pulmonary embolism or\n tracheobronchomalacia.\n\n" }, { "category": "ECG", "chartdate": "2119-08-21 00:00:00.000", "description": "Report", "row_id": 215379, "text": "Ventricular paced rhythm. Probable underlying atrial fibrillation.\nCompared to the previous tracing no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2119-08-21 00:00:00.000", "description": "Report", "row_id": 215602, "text": "Ventricular paced rhythm. Probable underlying atrial fibrillation.\nCompared to the previous tracing of atrial rhythm has changed.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2119-08-18 00:00:00.000", "description": "Report", "row_id": 215603, "text": "Sinus rhythm with atrial sensed and ventricular paced rhythm\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2119-08-18 00:00:00.000", "description": "Report", "row_id": 215604, "text": "Atrially sensed, ventricularly paced rhythm. Underlying rhythm is sinus\nrhythm. Compared to the previous tracing of there is no significant\ndiagnostic change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2198-09-03 00:00:00.000", "description": "ERCP BILIARY ONLY BY GI UNIT", "row_id": 1030225, "text": " 10:10 AM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: PLEASE REVIEW ERCP IMAGES DONE , BILIARY SLUDGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Suspected bile ducts stone\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with suspicions for gallbladder duct stone.\n\n ERCP: Ten single spot radiographic images were acquired by\n gastroenterologist, in the absence of radiologist.\n\n COMPARISON: ERCP on .\n\n FINDINGS: Contrast medium was injected resulting in complete retrograde\n opacification of the common hepatic ducts and antegrade opacification of the\n common bile ducts. There are two large filling defects in the common bile\n duct suggesting stones or gas bubbles, and small irregular filling defects in\n the lower common bile duct suggesting sludge. There is an apparent extraction\n procedure by inflated balloon, and a placement of Cotton- biliary stent.\n\n Please refer to the GI note for full report, assessment and recommendations.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028285, "text": " 11:30 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for NG tube placement.\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with possible ileus s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for NG tube placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 1:59 PM\n NGT extends below diaphragm but quite laterally into the lower abdomen. Could\n indicate an abdominal wall hernia.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 11:42\n\n INDICATION: NGT placement.\n\n FINDINGS:\n\n An NGT extends below the diaphragm, however, courses quite laterally and\n inferiorly in the abdomen. This may indicate an abdominal wall hernia.\n Correlation with administration of air and auscultation is recommended. Some\n dilated loops of large and small bowel were noted. No free air seen. Left\n basilar atelectasis and/or fluid stable in appearance.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028286, "text": ", MED 11:30 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for NG tube placement.\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with possible ileus s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for NG tube placement.\n ______________________________________________________________________________\n PFI REPORT\n NGT extends below diaphragm but quite laterally into the lower abdomen. Could\n indicate an abdominal wall hernia.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-25 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1028079, "text": " 5:08 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for stone or signs of cholecystitis/cholangitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with dilated CBD on osh CT,\n REASON FOR THIS EXAMINATION:\n eval for stone or signs of cholecystitis/cholangitis\n ______________________________________________________________________________\n WET READ: DXAe SAT 5:52 AM\n Nonobstructing stone in the common duct without evidence of CBD dilation,\n galbladder wall thickening or perichoecystic fluid to suggest acute\n cholecytitis, although intermittent obstruction is possible.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with dilated CBD at outside hospital. Evaluate\n for evidence of cholecystitis or cholangitis.\n\n COMPARISON: None.\n\n LIVER ULTRASOUND: There is no evidence of intra- or extra-hepatic biliary\n dilatation. Bile duct measures 5 mm. There is a stone in the common bile\n duct measuring 1 cm. There is no evidence of pericholecystic fluid or\n gallbladder wall thickening. Multiple other gallbladder wall stones are\n identified. The pancreatic head is unremarkable. The main portal vein\n demonstrates normal hepatopetal flow.\n\n IMPRESSION: stone in the common bile duct. No biliary obstruction. There is\n no evidence of acute cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1028276, "text": " 10:49 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Eval for obstruction\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with Cholangitis now with increasing distention\n REASON FOR THIS EXAMINATION:\n Eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL SERIES, , 10:52\n\n INDICATION: Increasing abdominal distention.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior film, there is increased distention of small\n bowel loops but increased air is seen within the colon as well. There is less\n distention of the gastric air bubble. Air density in the pelvis suggest the\n rectal vault is air-filled as well making a distal obstruction unlikely.\n Oral contrast is seen in the descending colon extending down to the sigmoid\n portion. There is no evidence of free air or pneumatosis or ascites.\n\n IMPRESSION: Findings are most consistent with an adynamic ileus with some\n increased distention of both small and large bowel with air.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-25 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1028686, "text": " 1:48 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 yr old F with gallstones admitted with pancreatitis and acute renal failure\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with gallstone, admitted with pancreatitis and\n acute renal failure.\n\n STUDY: ERCP. Six single spot view fluoroscopic radiographs were acquired by\n a gastroenterologist, in the absence of a radiologist.\n\n FINDINGS: Contrast medium was injected resulting in a retrograde\n opacification of the biliary tree. There is mild diffuse dilatation at the\n common bile duct. There are multiple rounded filling defects, ranging in size\n from 4-6 cm,representing gallstones, causing partial obstruction at the common\n bile duct. There are also multiple stones in the gallbladder. Per report, the\n stones in the CBD have been successfully extracted using a 15 mm balloon.\n\n Please refer to the GI note for full report, assessment, and recommendations.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028217, "text": ", MED 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please better evaluate possible left lower lobe infiltrate.\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with choledocholithiasis incidentally found to have a\n possible left lower lobe infiltrate on CXR.\n REASON FOR THIS EXAMINATION:\n Please better evaluate possible left lower lobe infiltrate.\n ______________________________________________________________________________\n PFI REPORT\n Accounting for slight positioning differences no significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029158, "text": ", V. MED 11R 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, fever\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with cholangitis, resolved, ileus, resolved. again low grade\n temp.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, fever\n ______________________________________________________________________________\n PFI REPORT\n Left pleural effusion, increased retrocardiac and left basilar opacity, likely\n atelectasis, although infection cannot be excluded in this area.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028216, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please better evaluate possible left lower lobe infiltrate.\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with choledocholithiasis incidentally found to have a\n possible left lower lobe infiltrate on CXR.\n REASON FOR THIS EXAMINATION:\n Please better evaluate possible left lower lobe infiltrate.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:09 AM\n Accounting for slight positioning differences no significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 05:15\n\n INDICATION: Possible left lower lobe infiltrate.\n\n COMPARISON: \n\n FINDINGS:\n\n Patient is in a more lordotic projection and accounting for this technical\n difference which creates an impression of increased prominence of the\n pulmonary vasculature, there is probably no significant interval change. Again\n there is increased density at the left CP angle with some increased\n retrocardiac density likely atelectasis. When feasible a lateral view will be\n most useful in assessment. Cardiac contour, pulmonary vascular markings are\n unchanged.\n\n IMPRESSION: Accounting for technical differences no significant interval\n change.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-30 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1029242, "text": " 4:06 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval L sided pleural effusion ?underlying compressive atelec\n Admitting Diagnosis: VOMITING\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent cholangitis, ileus, CXR wtih L pleural\n effusion/ATx but now having fever/leukocytosis\n REASON FOR THIS EXAMINATION:\n eval L sided pleural effusion ?underlying compressive atelectasis vs\n consolidation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:17 PM\n Bilateral pleural effusions, small-to-moderate on the left and small on the\n right, associated with bibasilar atelectasis most prominent on the left.\n There is no multifocal area of consolidation suspicious for infection.\n Scattered mediastinal lymph nodes are not enlarged. Airways are patent. The\n esophagus is slightly prominent, although this study is not tailored for this\n evaluation. If clinical symptoms of esophagitis are present, barium swallow\n could further characterize this.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITH CONTRAST\n\n REASON FOR EXAM: 70-year-old woman with recent cholangitis, ileus, left\n pleural effusion. Fever, leukocytosis; evaluate left-sided pleural effusion\n and underlying compressive atelectasis versus consolidation.\n\n No prior exam for comparison.\n\n TECHNIQUE: Chest MDCT was performed following intravenous Optiray using 5-mm\n and 1.25-mm axial slice thickness. Coronal and sagittal reformations were\n also obtained.\n\n FINDINGS: Bilateral pleural effusions are small-to-moderate on the left and\n small on the right. Associated compressive atelectasis is small on the right\n and more marked on the left, involving the lingula and all basal segments.\n Enhancement is homogeneous, suggesting compressive atelectasis and not\n pneumonia. Airways are patent to the subsegmental level. There is no other\n focal area of consolidation.\n\n There is no pericardial effusion. Scattered mediastinal lymph nodes are not\n enlarged using CT criteria. The largest lymph node is in the left lower\n paratracheal region and measures 8 mm. There is no lung nodule. The\n esophagus is seen slightly prominent, could be due to esophagitis or\n only inadequate distension during this study.\n\n This study was not tailored for subdiaphragmatic evaluation, but the upper\n abdomen is unremarkable. Bones are normal except to note degenerative changes\n in the spine.\n\n (Over)\n\n 4:06 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval L sided pleural effusion ?underlying compressive atelec\n Admitting Diagnosis: VOMITING\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Bilateral pleural effusions, most prominent on the left with adjacent\n basilar atelectasis. No suspicious consolidation worrisome for pneumonia.\n\n 2. Scattered not enlarged mediastinal lymph nodes are probably reactive.\n\n 3. Slightly prominent esophagus, could be due to inadequate distension or\n esophagitis, but difficult to assess without oral contrast. Correlate with\n clinical symptoms. If warranted, barium swallow could further characterize\n this.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-30 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1029243, "text": ", V. MED 11R 4:06 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval L sided pleural effusion ?underlying compressive atelec\n Admitting Diagnosis: VOMITING\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent cholangitis, ileus, CXR wtih L pleural\n effusion/ATx but now having fever/leukocytosis\n REASON FOR THIS EXAMINATION:\n eval L sided pleural effusion ?underlying compressive atelectasis vs\n consolidation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Bilateral pleural effusions, small-to-moderate on the left and small on the\n right, associated with bibasilar atelectasis most prominent on the left.\n There is no multifocal area of consolidation suspicious for infection.\n Scattered mediastinal lymph nodes are not enlarged. Airways are patent. The\n esophagus is slightly prominent, although this study is not tailored for this\n evaluation. If clinical symptoms of esophagitis are present, barium swallow\n could further characterize this.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1028153, "text": " 3:26 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for dilated loops of bowel consistent with i\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with choledocholithiasis and gallstone pancreatitis with\n question of ileus on outside hospital CT scan with distended abdomen on\n physical.\n REASON FOR THIS EXAMINATION:\n Please evaluate for dilated loops of bowel consistent with ileus.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 12:01 AM\n Dilated small and large bowel loops are demonstrated which can be seen with\n ileus. Followup recommended.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 15:39.\n\n INDICATION: Gallstone pancreatitis and ileus at outside hospital CT scan.\n\n FINDINGS:\n\n Somewhat underpenetrated film shows some air-filled loops of large and small\n bowel and a viscous left upper quadrant presumably the stomach. While this\n pattern is likely an adynamic ileus, a followup film or clinical correlation\n is suggested, since a low obstruction could appear in this manner as well. The\n hemidiaphragms are cut off from view, but there is no obvious free air and no\n pneumatosis.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1028154, "text": ", MED 3:26 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for dilated loops of bowel consistent with i\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with choledocholithiasis and gallstone pancreatitis with\n question of ileus on outside hospital CT scan with distended abdomen on\n physical.\n REASON FOR THIS EXAMINATION:\n Please evaluate for dilated loops of bowel consistent with ileus.\n ______________________________________________________________________________\n PFI REPORT\n Dilated small and large bowel loops are demonstrated which can be seen with\n ileus. Followup recommended.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028086, "text": " 6:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with shortness of breath, rule out CHF.\n\n COMPARISON: None.\n\n AP UPRIGHT CHEST: Heart size is normal. The left lower lung demonstrates a\n dense opacity that slopes upward. There is mild pulmonary vascular congestion\n with haziness of the hila noted. There is no pneumothorax or evidence of\n focal consolidation.\n\n IMPRESSION: Left lower lobe opacity of uncertain etiology. Cannot rule out\n pneumonia. Recommend PA and lateral chest.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-31 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1029475, "text": " 2:13 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: eval for cholecystitis, choledocholithiasis, cholangitis\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent cholangitis on Abx, now again with fever and\n leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, choledocholithiasis, cholangitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRSg FRI 4:31 PM\n 1. Small stones in distal common bile duct, but caliber of common bile duct\n decreased from .\n\n 2. Gallstones without evidence of cholecystitis.\n\n 3. Echogenic liver consistent with fatty infiltration. Limited study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent cholangitis, on antibiotics, now again with fever and\n leukocytosis. Evaluate for cholecystitis, choledocholithiasis, and\n cholangitis.\n\n COMPARISON: .\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n FINDINGS: The examination is markedly limited by body habitus. The liver is\n diffusely echogenic consistent with fatty infiltration without definite focal\n hepatic masses or intrahepatic biliary ductal dilation identified. Since the\n examination of , there has been a decrease in caliber of the\n common bile duct, which previously measured 7 mm and now measures 4 mm.\n A couple of tiny echogenic foci with posterior shadowing consistent with\n stones in the common bile duct are again noted but do not appear to occlude\n the duct. The portal vein is patent with flow in the appropriate direction.\n The gallbladder is contracted and contains numerous shadowing stones. There\n is no definite gallbladder wall edema to suggest acute cholecystitis. The\n son sign is negative. The imaged portion of the pancreas,\n including a portion of the pancreatic head and body, appear within normal\n limits. The pancreatic tail is obscured by overlying bowel gas.\n\n IMPRESSION:\n 1. Limited examination. Echogenic liver consistent with fatty infiltration,\n although other forms of liver disease including more significant hepatic\n fibrosis or cirrhosis, could result in a similar appearance.\n\n 2. Decreased caliber of the common bile duct since , now non-\n distended at 4 mm, but with small shadowing stones seen within the distal\n duct.\n\n 3. Cholelithiasis without evidence of cholecystitis.\n\n (Over)\n\n 2:13 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: eval for cholecystitis, choledocholithiasis, cholangitis\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n DR. SUN\n" }, { "category": "Radiology", "chartdate": "2198-08-31 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1029476, "text": ", V. MED 11R 2:13 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: eval for cholecystitis, choledocholithiasis, cholangitis\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent cholangitis on Abx, now again with fever and\n leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, choledocholithiasis, cholangitis\n ______________________________________________________________________________\n PFI REPORT\n 1. Small stones in distal common bile duct, but caliber of common bile duct\n decreased from .\n\n 2. Gallstones without evidence of cholecystitis.\n\n 3. Echogenic liver consistent with fatty infiltration. Limited study.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029157, "text": " 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, fever\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with cholangitis, resolved, ileus, resolved. again low grade\n temp.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, fever\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:26 PM\n Left pleural effusion, increased retrocardiac and left basilar opacity, likely\n atelectasis, although infection cannot be excluded in this area.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n COMPARISON: .\n\n HISTORY: Low-grade fever, evaluate for infiltrate.\n\n FINDINGS: There is a persistent small left-sided pleural effusion with\n associated atelectasis. Increased retrocardiac opacity maybe due to\n atelectasis or consolidation. No other consolidations are identified. The\n osseous structures are grossly unremarkable.\n\n IMPRESSION: Left pleural effusion with increased retrocardiac and left\n basilar opacity. This likely represents atelectasis, although infection\n cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-28 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 1028671, "text": " 1:19 PM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: eval ileus\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent ileus, s/p BM, NGT removed.\n REASON FOR THIS EXAMINATION:\n eval ileus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa TUE 4:08 PM\n Resolving ileus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with recent cholangitis and paralytic ileus, now\n has bowel movement and nasogastric tube removed.\n\n STUDY: AP abdominal radiograph.\n\n COMPARISON: AP abdominal radiograph on .\n\n FINDINGS: There is interval marked decrease of small bowel distention. There\n is normal gas-filled, nondistended colon with decrease of retained p.o.\n contrast. There is normal air in rectal vault. Compared to prior study, these\n findings represent resolving ileus.\n\n IMPRESSION: Resolving ileus.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-28 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 1028672, "text": ", V. MED 11R 1:19 PM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: eval ileus\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent ileus, s/p BM, NGT removed.\n REASON FOR THIS EXAMINATION:\n eval ileus\n ______________________________________________________________________________\n PFI REPORT\n Resolving ileus.\n\n" }, { "category": "ECG", "chartdate": "2198-08-25 00:00:00.000", "description": "Report", "row_id": 223812, "text": "Sinus rhythm. Poor R wave progression - possible prior anteroseptal myocardial\ninfarction versus normal variant. Low QRS voltage in the precordial leads. No\nprevious tracing available for comparison.\n\n" }, { "category": "Physician ", "chartdate": "2198-08-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 633442, "text": "Chief Complaint: Sepsis\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:28 AM\n URINE CULTURE - At 12:28 AM\n Overall improved, but remains nauseous, vomitting bilious material.\n Abd more distended. No flattus.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\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 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, 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: Abdominal pain, Nausea, No(t) Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, 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: Mild\n Pain location: RUQ\n Flowsheet Data as of 10:27 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 (97.9\n HR: 67 (64 - 80) bpm\n BP: 136/67(84) {109/52(66) - 137/74(85)} mmHg\n RR: 20 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,850 mL\n 967 mL\n PO:\n TF:\n IVF:\n 1,850 mL\n 967 mL\n Blood products:\n Total out:\n 1,260 mL\n 1,040 mL\n Urine:\n 1,010 mL\n 1,015 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 590 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///20/\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, 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: No(t) Systolic,\n No(t) 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: No(t) Soft, No(t) Non-tender, Bowel sounds present,\n Distended, Tender: RUQ, No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) 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 11.5 g/dL\n 190 K/uL\n 123 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 39 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.4 %\n 13.2 K/uL\n [image002.jpg]\n 03:50 AM\n WBC\n 13.2\n Hct\n 33.4\n Plt\n 190\n Cr\n 2.1\n TropT\n 0.02\n Glucose\n 123\n Other labs: CK / CKMB / Troponin-T:43/3/0.02, ALT / AST:100/38, Alk\n Phos / T Bili:80/1.0, Amylase / Lipase:112/266, Differential-Neuts:84.8\n %, Band:0.0 %, Lymph:11.7 %, Mono:3.3 %, Eos:0.1 %, Albumin:3.1 g/dL,\n LDH:188 IU/L\n Assessment and Plan\n Ascending cholangitis, sepsis.\n SEPSIS -- Improved. Monitor VS. Continue supportive care.\n CHOLANGITIS -- common bile duct stone. S/P ERCP extraction of multiple\n biliary stones. Monitor LFTs. Continue antimicrobials.\n PANCREATITIS -- improved. Monitor serial amylase/lipase.\n ACUTE RENAL FAILURE -- improved. Monitor BUN, creat.\n ILEUS -- NPO. Ilieus likely from infection, instrumentation,\n narcotics. Evidence for significant air in stomach on KUB yesterday.\n F/U KUB, if remains distended, then place NGT to decompress.\n NUTRITIONAL SUPPORT -- NPO pending evaluation.\n LLL INFILTRATE -- possible aspiration in setting of ERCP. Monitor.\n FLUIDS -- euvolemic. Monitor I/O. Maintain balance.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-08-25 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 633425, "text": "Chief Complaint: Vomiting and diarrhea\n HPI:\n 70 yo F with a history of HTN and hypercholesterolemia who presents\n with vomiting and diarrhea, found to have acute choledocholithiasis\n with complications of gallstone pancreatitis.\n .\n The patient reports that she had 2-3 days of vomiting and diarrhea\n prior to presentation. She notes poor PO intake over this time period.\n She denies any associated symptoms including no fevers, chest pain,\n shortness of breath, dizziness, lightheadedness or dysuria. She does\n note that she had a similar episode several months ago where she was\n afflicted with 1 week of vomiting and diarrhea. She assumed her\n symptoms at that time were due to the flu and they did resolve without\n intervention.\n .\n The patient initially presented to an Hospital. She was\n noted to have triage bp 59/36, improved to 118/44 with 2 L NS. She was\n noted to have a WBC 24,000 with BUN/Cr 44/4.2 (baseline unknown). CT\n abdomen/pelvis reportedly revealed a dilated common bile duct,\n pancreatits and question of an ileus. She received\n Piperacillin/Tazobactam 3.375g. She was transferred to for\n further care including urgent ERCP.\n .\n On presentation to ED, T 98.6 HR 75 BP 108/55 18 99% 2L. While in\n the ED, the patient did spike to 101.3 and had hypotension to 66/38.\n She received a total of 5 L NS and 1 dose of pip/tazo 4.5gm with\n improvement in bp to 100/43. She underwent RUQ U/S revealing a\n non-obstructive common bile duct stone without dilatation, gallbladder\n thickening or pericholecystic fluid. Intermittent obstruction could not\n be excluded. Given her history, she was taken for ERCP where she\n reportedly had several large stones extracted with good biliary\n drainage after extraction. No pus was noted. Of note, she was also\n found on routine blood work to have a Cr of 3.9.\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 - Lisinopril/HCTZ 10/12.5mg Daily\n - Atenolol 50mg Daily\n - Simvastatin 20mg Daily in the evening\n Past medical history:\n Family history:\n Social History:\n - HTN\n - Hypercholesterolemia\n No family history of GI malignancy or gallbladder disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives alone. Denies tobacco use. Notes rare EtOH use.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n 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 Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 64 (64 - 69) bpm\n BP: 118/61(76) {109/61(76) - 118/74(82)} mmHg\n RR: 24 (18 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 20 mL\n PO:\n TF:\n IVF:\n 20 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 20 mL\n Respiratory\n SpO2: 99%\n Physical Examination\n Gen: Well-appearing. Mildly sedated. NAD.\n HEENT: PERRL.\n CV: RRR. Normal S1 and S2. No M/R/G.\n Pulm: CTA bilaterally.\n Abd: Obese, mildly distended. Normoactive bowel sounds. No tenderness,\n rebound or guarding.\n Ext: No edema.\n Neuro: A&O x3.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Na 138, K 4.7, Cl 99, Bicarb 23, BUN/Cr\n 49/3.9, glucose 137, WBC 16.9 (71% N, 11% B, 10% L, 5% Atypicals), Hct\n 36.7, platelets 308, ALT 184, AST 101, AP 113, T Bili 2.0, 901, Lip\n 3279.\n .\n CK 31\n .\n Lactate 1.9\n .\n INR 1.2\n .\n UA RBC 0-2, WBC , Neg Leuk, Neg Nit, Tr Prot.\n Imaging: RUQ U/S (): Nonobstructing stone in the common duct\n without evidence of CBD dilation, galbladder wall thickening or\n perichoecystic fluid to suggest acute cholecytitis, although\n intermittent obstruction is possible.\n .\n CXR (): Left lower lobe opacity of uncertain etiology. Cannot\n rule out pneumonia.\n Microbiology: Blood culture (): Pending.\n ECG: Sinus rhythm at a rate of 71. Normal axis and intervals. Q wave in\n III. No acute ST or T wave changes. Unchanged from which is\n the only available prior for comparison.\n Assessment and Plan\n 70 yo F with a history of HTN and hypercholesterolemia who presents\n with vomiting and diarrhea, found to have acute choledocholithiasis\n with complications of gallstone pancreatitis, hypotension and acute\n renal failure.\n .\n # Choledocholithiasis, possible complication of ascending cholangitis.\n Significant infection with fluid responsive hypotension and bandemia.\n S/p ERCP with stone extraction and report of good drainage. No pus\n visualized.\n - Continue Zosyn, renally dosed.\n - Follow-up outside hospital and local blood cultures. Reculture if\n spikes.\n - Continue volume rescucitation with IV NS. Low threshold for central\n line and sepsis protocol.\n .\n # Pancreatitis. Likely gallstone mediated.\n - NPO, advance diet slowly.\n - Trend pancreatic enzymes.\n .\n # ?Ileus? Reportedly seen on OSH CT scan. Abdomen mildly distended with\n normal bowel sounds.\n - Abdominal plain film.\n - Obtain outside hospital CT scan.\n - NPO, advance diet slowly.\n .\n # Renal failure. Baseline unknown. Likely pre-renal secondary to\n infection and SIRS physiology thought cannot exclude ATN secondary to\n hypotension. Cr already improving from outside hospital measurements\n with volume rescucitation.\n - Trend Cr with volume rescucitation. Monitor urine output.\n .\n # Possible pulmonary opacity on CXR.\n - Repeat CXR. Any infiltrate will likely be covered by zosyn but will\n better evaluate on repeat film.\n .\n # Hypertension. Hold antihypertensives.\n .\n # Hypercholesterolemia. Hold statin therapy in the setting of\n transaminitis.\n .\n # FEN: NPO. Advance diet when feeling better and declining pancreatic\n enzymes.\n .\n # Prophylaxis: PPI, heparin subq, bowel regimen.\n .\n # Access: Peripheral IVs.\n .\n # Contact: (son) \n .\n # Code: Presumed full.\n .\n # Dispo: If hemodynamically stable, can be called out of the ICU in the\n morning.\n .\n ICU Care\n Prophylaxis:\n DVT: SQ UF Heparin\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2198-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 633431, "text": "Sepsis without organ dysfunction\n Assessment:\n Hypotensive in OSH and ED, fluid resuscitated w 7L iv fld. Wbc 24,\n down to 16.9. s/p ERCP . Temp spiked to 101.0 pr at midnoc. CXR\n noted LL opacity. LS clear, diminished at bases. No cough or sob,\n although pt reported a dry cough pta.\n Action:\n Blood and urine cx. Iv zosyn. 100mls NS/hr o/n. repeat cxr this am.\n Response:\n Stable BP, no tachycardia.\n Plan:\n Monitor temps, VS, LS. F/u on cx and cxr.\n Cholecystitis, calculous\n Assessment:\n S/p ERCP. Elevated liv and pancreatic . ? ileus noted on CT\n scan. C/o mild pain in abd and back. Abd distended, hypoactive BS.\n Pt reported having sm amt diarrhea prior to ERCP and on previous days.\n Action:\n Keep NPO except meds and ice chips until pancreatic trend down.\n Med w morphine 1mg x1 for back pain.\n Response:\n Good response from morphine. No further c/o abd pain.\n Plan:\n Monitor for pain, abd distention, BS. Medicate prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Elevated BUN/Cr on adm 49/3.9. ? sepsis/atn.\n Action:\n IVF for hydration while npo. Am labs.\n Response:\n Good u/o.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2198-08-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 633446, "text": "Chief Complaint: Sepsis\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 12:28 AM\n URINE CULTURE - At 12:28 AM\n Overall improved, but remains nauseous, vomitting bilious material.\n Abd more distended. No flattus.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\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 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, 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: Abdominal pain, Nausea, No(t) Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, 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: Mild\n Pain location: RUQ\n Flowsheet Data as of 10:27 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 (97.9\n HR: 67 (64 - 80) bpm\n BP: 136/67(84) {109/52(66) - 137/74(85)} mmHg\n RR: 20 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,850 mL\n 967 mL\n PO:\n TF:\n IVF:\n 1,850 mL\n 967 mL\n Blood products:\n Total out:\n 1,260 mL\n 1,040 mL\n Urine:\n 1,010 mL\n 1,015 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n 590 mL\n -73 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///20/\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, 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: No(t) Systolic,\n No(t) 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: No(t) Soft, No(t) Non-tender, Bowel sounds present,\n Distended, Tender: RUQ, No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) 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 11.5 g/dL\n 190 K/uL\n 123 mg/dL\n 2.1 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 39 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.4 %\n 13.2 K/uL\n [image002.jpg]\n 03:50 AM\n WBC\n 13.2\n Hct\n 33.4\n Plt\n 190\n Cr\n 2.1\n TropT\n 0.02\n Glucose\n 123\n Other labs: CK / CKMB / Troponin-T:43/3/0.02, ALT / AST:100/38, Alk\n Phos / T Bili:80/1.0, Amylase / Lipase:112/266, Differential-Neuts:84.8\n %, Band:0.0 %, Lymph:11.7 %, Mono:3.3 %, Eos:0.1 %, Albumin:3.1 g/dL,\n LDH:188 IU/L\n Assessment and Plan\n Ascending cholangitis, sepsis.\n SEPSIS -- Improved. Monitor VS. Continue supportive care.\n CHOLANGITIS -- common bile duct stone. S/P ERCP extraction of multiple\n biliary stones. Monitor LFTs. Continue antimicrobials.\n PANCREATITIS -- improved. Monitor serial amylase/lipase.\n ACUTE RENAL FAILURE -- improved. Monitor BUN, creat.\n ILEUS -- NPO. Ilieus likely from infection, instrumentation,\n narcotics. Evidence for significant air in stomach on KUB yesterday.\n F/U KUB, if remains distended, then place NGT to decompress.\n NUTRITIONAL SUPPORT -- NPO pending evaluation.\n LLL INFILTRATE -- possible aspiration in setting of ERCP. Monitor.\n FLUIDS -- euvolemic. Monitor I/O. Maintain balance.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-08-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 633449, "text": "Presented to OSH with 2 day hx. of N/V/D. Olso found to have CBD\n dilitation and intermitten hypotension. Transfered to for ERCP.\n Hypotensive to 60's in ED but fluid responsive. RUQ US in ED showed\n CBD stones and pancreatitis and elevated LFTs.\n ERCP done in suite today with sphincterotomy and about 15 stones out.\n Transftered to MICU for +bandemia on admission and hypotension in ED.\n Pt. was intubated for ERCP but transferred to MICU extubated.\n Sepsis without organ dysfunction\n Assessment:\n Pt. presented to ED with hypotension and elevated WBC and bandemia.\n Action:\n IV Zosyn as ordered.\n Response:\n BP remains stable with SBP>110. Afebrile.\n Plan:\n Cont. to monitor CBC, and BP. Cont. IV Abx.\n Cholecystitis, calculous\n Assessment:\n Pt. with N/V/D 2 days prior to admission. RUQ US + for gallstones.\n Amylase and Lipase elevated.\n Action:\n ERCP done with many stones and sphincterotomy as well as balloon\n sweep. Cont. bowel rest with IVF and NPO.\n Response:\n Denies pain at this time. LFTs as well as amylase and lipase\n significantly down this AM.\n Plan:\n Continue to monitor. Morphine PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 49, creatinine 3.9 on admission to ED. Pt. denies Hx. Of kidney\n disease.\n Action:\n IVF for hydration while Pt. NPO.\n Response:\n Urine output adequate. Creatnine down to 2.1 this AM.\n Plan:\n Monitor urine output . Cont. follow AM labs.\n Problem - Ileus\n Assessment:\n Pt. with ? ileus on Abd. CT from OSH prior to admission. Abd. Distended\n and no BS heard over abd. Pt. denies pain but had 2 episodes of nausea\n with small amount of bile. Repeat KUB in radiology this AM confirmed\n illeus.\n Action:\n NGT inserted by house staff and connected to intermiten low wall\n suction. Surgical consult in place.\n Response:\n 1200cc drained within first 30 min. of connecting NGT to suction.\n Additional 400cc of bile emptied before transfer to floor. Pt. states\n she feels better.\n Plan:\n Cont. with NGT to suction. Plan for cholycystectomy after acute\n episode over.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VOMITING\n Code status:\n Full code\n Height:\n Admission weight:\n 88.6 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: hyperlipedemia.\n Surgery / Procedure and date: c-section, hysterectomy, L ankle ORIF, L\n wrist ORIF\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:137\n D:66\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 78 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 24h total in:\n 1,455 mL\n 24h total out:\n 3,160 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:50 AM\n Potassium:\n 3.9 mEq/L\n 03:50 AM\n Chloride:\n 107 mEq/L\n 03:50 AM\n CO2:\n 20 mEq/L\n 03:50 AM\n BUN:\n 39 mg/dL\n 03:50 AM\n Creatinine:\n 2.1 mg/dL\n 03:50 AM\n Glucose:\n 123 mg/dL\n 03:50 AM\n Hematocrit:\n 33.4 %\n 03:50 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs, Foley cath\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: See initial admission note for description of all jewelry\n Transferred from: MICU 403\n Transferred to: 1176\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2198-08-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 633428, "text": "Presented to OSH with 2 day hx. of N/V/D. Olso found to have CBD\n dilitation and intermitten hypotension. Transfered to for ERCP.\n Hypotensive to 60's in ED but fluid responsive. RUQ US in ED showed\n CBD stones and pancreatitis and elevated LFTs.\n ERCP done in suite today with sphincterotomy and about 15 stones out.\n Transftered to MICU for +bandemia on admission and hypotension in ED.\n Pt. was intubated for ERCP but transferred to MICU extubated.\n Sepsis without organ dysfunction\n Assessment:\n Pt. presented to ED with hypotension and elevated WBC and bandemia.\n Action:\n IVF in ED. Started on IV Zosyn.\n Response:\n BP up with IVF. BP remains stable after procedure with SBP>110.\n Afebrile.\n Plan:\n Cont. to monitor CBC, and BP. Cont. IV Abx.\n Cholecystitis, calculous\n Assessment:\n Pt. with N/V/D 2 days prior to admission. RUQ US + for gallstones.\n Amylase and Lipase elevated.\n Action:\n ERCP done today with many stones and sphincterotomy as well as balloon\n sweep.\n Response:\n Pt. tolerated procedure well. Denies pain at this time.\n Plan:\n Continue to monitor. Morphine PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 49, creatinine 3.9 on admission to ED. Pt. denies Hx. Of kidney\n disease.\n Action:\n IVF for hydration while Pt. NPO.\n Response:\n Urine output adequate. Labs in AM.\n Plan:\n Monitor urine output . Encourage PO intake as Pt. tolerates. F/U AM\n labs.\n" }, { "category": "Physician ", "chartdate": "2198-08-25 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 633429, "text": "Chief Complaint: nausea/vomitting/diarrhea\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 70 yo women with 2-3 of N/V/D. Similar episode 1 month ago that\n resolved. At OSH SBP 59, reponded to 3L IVF. WBC 24K, Creatinine 4.2\n CT abd with dilated CBD. Got Zosyn. Transferred to ED where VS\n were stable intially then febrile to 103, HOTNsive to 66/38. Got\n addional 5L and more zosyn here. BP improved. RUQ US with\n non-obstructive CBD stone. Got ERCP - several stones were extracted.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n increased cholesterol\n Meds:\n Simvastatin\n HCTZ\n Lisinopril\n Atenolol\n No GI Malignancy\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: RAre\n Other:\n Review of systems:\n Constitutional: Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: Cough\n Gastrointestinal: Nausea, Emesis, Diarrhea\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 08:49 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: 36.4\nC (97.6\n HR: 66 (64 - 69) bpm\n BP: 111/55(69) {109/55(69) - 118/74(82)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,507 mL\n PO:\n TF:\n IVF:\n 1,507 mL\n Blood products:\n Total out:\n 0 mL\n 805 mL\n Urine:\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 702 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 308\n 36\n 137\n 3.9\n 49\n 23\n 99\n 4.7\n 138\n 16,900\n [image002.jpg]\n Other labs: ALT / AST:184/101, Alk Phos / T Bili:/2.0, Amylase /\n Lipase:, Differential-Neuts:71, Band:11, Lactic Acid:1.9\n Fluid analysis / Other labs: U/A neg leuks\n Imaging: CXR: Left sided infiltrate versus effusion.\n Microbiology: Blood Cx Pending\n ECG: Sinus Rhythm\n Assessment and Plan\n Choledocholithiasis +/- ascending cholangitis, pancreatitis, septic\n shock Continue zosyn. Volume resuscitation with IVF. Continue NPO.\n trend pancreatic enzymes.\n Ileus: Could be from pancreatitis.\n Renal Failure: Unclear baseline, likely hypovolemia +/- ATN from\n pancreatitis and sepsis.\n CXR: Left sided infiltrate versus effusion. Will need followup.\n Would be covered by zosyn.\n Anion gap acidosis: NL lactate, likely from renal failure.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 18 Gauge - 03:00 PM\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 Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2198-08-25 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 633430, "text": "Chief Complaint: nausea/vomitting/diarrhea\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 70 yo women with 2-3 of N/V/D. Similar episode 1 month ago that\n resolved. At OSH SBP 59, reponded to 3L IVF. WBC 24K, Creatinine 4.2\n CT abd with dilated CBD. Got Zosyn. Transferred to ED where VS\n were stable intially then febrile to 103, HOTNsive to 66/38. Got\n addional 5L and more zosyn here. BP improved. RUQ US with\n non-obstructive CBD stone. Got ERCP - several stones were extracted.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n increased cholesterol\n Meds:\n Simvastatin\n HCTZ\n Lisinopril\n Atenolol\n No GI Malignancy\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: RAre\n Other:\n Review of systems:\n Constitutional: Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: Cough\n Gastrointestinal: Nausea, Emesis, Diarrhea\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 08:49 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: 36.4\nC (97.6\n HR: 66 (64 - 69) bpm\n BP: 111/55(69) {109/55(69) - 118/74(82)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,507 mL\n PO:\n TF:\n IVF:\n 1,507 mL\n Blood products:\n Total out:\n 0 mL\n 805 mL\n Urine:\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 702 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 308\n 36\n 137\n 3.9\n 49\n 23\n 99\n 4.7\n 138\n 16,900\n [image002.jpg]\n Other labs: ALT / AST:184/101, Alk Phos / T Bili:/2.0, Amylase /\n Lipase:, Differential-Neuts:71, Band:11, Lactic Acid:1.9\n Fluid analysis / Other labs: U/A neg leuks\n Imaging: CXR: Left sided infiltrate versus effusion.\n Microbiology: Blood Cx Pending\n ECG: Sinus Rhythm\n Assessment and Plan\n Choledocholithiasis +/- ascending cholangitis, pancreatitis, septic\n shock Continue zosyn. Volume resuscitation with IVF. Continue NPO.\n trend pancreatic enzymes.\n Ileus: Could be from pancreatitis.\n Renal Failure: Unclear baseline, likely hypovolemia +/- ATN from\n pancreatitis and sepsis.\n CXR: Left sided infiltrate versus effusion. Will need followup.\n Would be covered by zosyn.\n Anion gap acidosis: NL lactate, likely from renal failure.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 18 Gauge - 03:00 PM\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 Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-08-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 633435, "text": "Sepsis without organ dysfunction\n Assessment:\n Hypotensive in OSH and ED, fluid resuscitated w 7L iv fld. Wbc 24,\n down to 16.9. s/p ERCP . Temp spiked to 101.0 pr at midnoc. CXR\n noted LL opacity. LS clear, diminished at bases. No cough or sob,\n although pt reported a dry cough pta.\n Action:\n Blood and urine cx. Iv zosyn. 100mls NS/hr o/n. repeat cxr this am.\n Response:\n Stable BP, no tachycardia. Temp down to 98.8 po at 0400 w/o Tylenol.\n Plan:\n Monitor temps, VS, LS. F/u on cx and cxr.\n Cholecystitis, calculous\n Assessment:\n S/p ERCP. Elevated liv and pancreatic . ? ileus noted on CT\n scan. C/o mild pain in abd and back. Abd distended, hypoactive\n BS. Pt reported having sm amt diarrhea prior to ERCP and on previous\n days.\n Action:\n Keep NPO except meds and ice chips until pancreatic trend down.\n Med w morphine 1mg x2 for back pain and some abd pain. Am labs.\n Response:\n Good response from morphine. Am labs show liv and pancreatic \n all decreased.\n Plan:\n Monitor for pain, abd distention, BS. Medicate prn. Discuss advancing\n diet w team.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Elevated BUN/Cr on adm 49/3.9. ? sepsis/atn.\n Action:\n IVF for hydration while npo. Am labs.\n Response:\n Good u/o, 90-100mls/hr. Am bun/cr down to 39/2.1.\n Plan:\n Cont to monitor.\n" } ]

[ { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684081, "text": "Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684083, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683838, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683841, "text": "44 y/o M with a PMH significant for asthma, developmental delay,\n hiatal hernia, gastro esophogeal stricture, esophagitis and Crohn's\n disease, who presented to the ED complaining of N/V and a sensation of\n food stuck in his throat. CXR inidicative of LLL PNA possibly to\n aspiration and he was started on levoquin/flagyl and admitted to the\n M/SICU for an EGD and monitoring.\n Since admission the EGD was performed successfully @ the bedside. A\n food particle was visualized at the gastroesophgeal junction and\n advanced, post procedure Mr. reports feeling\nbetter\n. He\n remained in the ICU overnight for closer monitoring as he continues to\n sat 89- 92% on 6 liters nasal and has no prior hx of supplemental 02\n requirements.\n Food Impaction\n Assessment:\n Initially c/o food stuck in throat, N/V\n Action:\n EGD performed, @ bedside, administered 50mcg fent and 3mg versed as\n moderate sedation for procedure\n Response:\n Food particle visulized and advanced beyond the esophogeal junction,\n temporarily desat to high 70\ns during EGD requiring 100% non\n rebreather, quickly rebounded low 90\ns post procedure\n Plan:\n Diet advanced to regular this AM, probable call out\n Hypoxemia\n Assessment:\n LS rhonchi upper lobes dimished @ bases w/ occasional exp wheezes, sats\n 89\n 92 % on 6 liters nasal, RR 22\n 30 non labored\n Action:\n Encouraged C/DB, expectorated sputum sample sent, administered\n levoquin/flagyl, attempted to wean supplemental 02\n Response:\n Unable to wean 02 secondary to desats to mid 80\ns on 4 liters\n Plan:\n Cont abx as ordered, monitor resp status, wean 02 as toelrated.\n" }, { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684135, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 90-91%, RR 26-40\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow/brownish secretions. Pm blood gas\n Action:\n Continued O2 4L nasal canula and 50% face tent, encouraged deep\n breathing and cough exercises, nebs given. sputum culture sent\n Response:\n Plan:\n Continue wean O2 as tolerated, continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684137, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:15 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 88 (85 - 116) bpm\n BP: 125/67(81) {109/55(75) - 141/81(91)} mmHg\n RR: 30 (27 - 43) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n PO:\n 1,690 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\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 183 K/uL\n 12.5 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684138, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - o2 sats dropped to 90% when face mask not on with NC, so keep both on\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:15 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 88 (85 - 116) bpm\n BP: 125/67(81) {109/55(75) - 141/81(91)} mmHg\n RR: 30 (27 - 43) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n PO:\n 1,690 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\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 183 K/uL\n 12.5 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs, sputum cxs\n .\n #) Hypoxia - Likely secondary to possible aspiration PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n - Bolus 1 L NS\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n .\n #) Hypothyroidism\n Elevated TSH, consider decreasing levothyroxine on\n dc.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684140, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 90-91%, RR 26-40\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow/brownish secretions. Pm blood gas\n 7.42/41/65/1/28, MD aware, wants continue monitor O2 sats >90%\n Action:\n Continued O2 4L nasal canula and 50% face tent, encouraged deep\n breathing and cough exercises, nebs given. sputum culture sent\n Response:\n Stable overnight, RR 30-40\ns, slept well, WBC 12.3, continue to have\n low grade temp\n Plan:\n Continue wean O2 as tolerated, continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs\n ? C/O to floor\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683949, "text": "Chief Complaint: 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 24 Hour Events:\n Remains with requirement for supplemental oxygen.\n Develops tachypnea when stimulated, otherwise comfortable.\n Cough.\n No emesis.\n History obtained from Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 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: Cough, No(t) Dyspnea, 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, 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 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 10:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.2\n HR: 103 (97 - 109) bpm\n BP: 109/68(75) {109/64(75) - 141/122(126)} mmHg\n RR: 33 (24 - 36) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 809 mL\n PO:\n 240 mL\n 480 mL\n TF:\n IVF:\n 1,100 mL\n 329 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n 409 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General Appearance: 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, 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n 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: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , 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, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 13.8 g/dL\n 223 K/uL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR ) LLL infiltrate\n Assessment and Plan\n 44 yom with developmental delay, esophageal stricture admitted with\n food impaction and pneumonia.\n FOOD IMPACTION -- Esophogeal stricture. s/p EGD with movement of food\n into stomach. No further intervention. Continue PPI.\n PNEUMONIA -- likely aspiration in context of esophogeal food\n impaction. Continue antimicrobials, MDIs. Encourage cough.\n HYPOXEMIA -- attributed to pneumonia. Contineu supplimental oxygen,\n maintain SaO2 > 90%.\n NAUSEA/VOMMITTING -- attributed to food impaction, but now improved.\n ACUTE RENAL FAIULRE -- likely pre-renal. Hydrating with IVF and will\n trend creatinine\n HYPOTHYROIDISM -- elevated TSH. Will check free T4\n BIPOLAR DISORDER -- continue home meds\n CROHN'S DISEASE -- continue asacol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\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: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683962, "text": "TITLE:\n Chief Complaint: hypoxia,\nfood stuck in throat\n 24 Hour Events:\n ENDOSCOPY - At 07:46 PM\n NASAL SWAB - At 08:52 PM\n URINE CULTURE - At 08:52 PM\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 105 (97 - 109) bpm\n BP: 119/69(81) {112/64(76) - 141/122(126)} mmHg\n RR: 32 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 294 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 294 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, shovel mask\n SpO2: 90%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, well appearing, tachypnec\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus.\n PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: Rhonchorous bilaterally, coughing\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Peripheral Vascular: strong DP and radial pulses\n Labs / Radiology\n 223 K/uL\n 13.8 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs, sputum cxs\n .\n #) Hypoxia - Likely secondary to possible aspiration PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n - Bolus 1 L NS\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n .\n #) Hypothyroidism\n Elevated TSH, consider decreasing levothyroxine on\n dc.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition: PO\n Glycemic Control: n/a\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: will start\n Stress ulcer: PPI, bowel regimen\n VAP:\n Comments:\n Communication: Comments: with patient. /mother\n . /sister . Group home\n , .\n Code status: Full\n Disposition: monitor today, to floor when sats stable\n" }, { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684252, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 92-97% RR 26-40\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow/brownish secretions.\n Action:\n Continued O2 4L nasal canula , encouraged deep breathing and cough\n exercises oob today with physical therapy, sats low 90\ns while\n ambulating\n Response:\n Sats have been increasing all day, on 4l/nc\n Plan:\n Continue wean O2 as tolerated, continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs ? call out tomorrow\n stayed in unit today due to it was thought that pt. was going to\n trigger on the floor.\n" }, { "category": "Nursing", "chartdate": "2133-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684050, "text": "44 y/o M with a PMH significant for asthma, developmental delay, hiatal\n hernia, gastro esophogeal stricture, esophagitis and Crohn's disease,\n who presented to the ED complaining of N/V and a sensation of food\n stuck in his throat. CXR inidicative of LLL PNA possibly to\n aspiration and he was started on levoquin/flagyl and admitted to the\n M/SICU for an EGD and monitoring.\n Hypoxemia\n Assessment:\n Patient with LLL PNA.\n Action:\n Remains on O2 via NC at 3l/min and face tent at 50%. ABG done see flow\n for the results. No new interventions at this time.\n Response:\n Patient with coarse rhonchi bilaterally and productive cough. He has\n been maintaining saturations in the low 90\ns not getting higher than\n 94%. He can desaturated to the mid 80\ns with excessive coughing and\n once the face tent is off for short periods. Once he has the tent back\n on he quickly recovers. The patient remains afebrile throughout the\n shift.\n Plan:\n Continue to monitor respiratory status.\n Patient fed soft diet today without any difficulty.\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684431, "text": "Pt is 44M with developmental delay admitted from group home\n with fever, cough and sensation of food caught in his throat. On EGD\n pt found to have food proximal to esophageal stricture which was\n advanced into stomach. Pt was hypoxic on RA likely aspiration PNA.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684433, "text": "Pt is 44M with developmental delay admitted from group home with\n fever, cough and sensation of food caught in his throat. On EGD pt\n found to have food proximal to esophageal stricture which was advanced\n into stomach. Pt was hypoxic on RA likely aspiration PNA.\n Hypoxemia\n Assessment:\n LS coarse with scattered rhonchi, diminished at bases\n Spo2 95-97% on 1L NP, pt requests oxygen as his very anxious about\n being short of breath\n SpO2 94% on RA\n Action:\n Pt ambulated ~250 feet with 2 contact guard assist\n Pt sat in chair x 2 hours\n Medicated x1 with guiafenisen and codeine\n Pt encouraged to cought and deep breathe, encouraged to use IS\n Response:\n Pt became acutely anxious while ambulating began coughing\n uncontrollably\n Pt tolerated being OOB fairly well\n Plan:\n Activity progression\n Aggressive pulmonary toilet\n Continue antibiotics as ordered\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 106.8 kg\n Daily weight:\n 106.2 kg\n Allergies/Reactions:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Precautions:\n PMH: Asthma\n CV-PMH:\n Additional history: hypothyroid, developmental disorder, chrons, GERD,\n bipolar, anxiety\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:69\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 32 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 300 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:48 AM\n Potassium:\n 3.8 mEq/L\n 03:48 AM\n Chloride:\n 105 mEq/L\n 03:48 AM\n CO2:\n 26 mEq/L\n 03:48 AM\n BUN:\n 14 mg/dL\n 03:48 AM\n Creatinine:\n 0.9 mg/dL\n 03:48 AM\n Glucose:\n 124 mg/dL\n 03:48 AM\n Hematocrit:\n 38.8 %\n 05:20 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: MICU/SICU FN 410\n Transferred to: RS 1167\n Date & time of Transfer: 04:00 PM\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684429, "text": "Pt is 44M with developmental delay admitted from group home\n with fever, cough and sensation of food caught in his throat. On EGD\n pt found to have food proximal to esophageal stricture which was\n advanced into stomach. Pt was hypoxic on RA likely aspiration PNA.\n" }, { "category": "Physician ", "chartdate": "2133-05-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684414, "text": "Chief Complaint: 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 24 Hour Events:\n Continues to experience cough, somewhat improved.\n Continues with requirement for supplimental oxygen.\n Cough remains, but slowling improving.\n History obtained from Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\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 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: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, 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: 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 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (57 - 91) bpm\n BP: 140/55(127) {114/14(35) - 146/84(127)} mmHg\n RR: 31 (20 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.2 kg (admission): 106.8 kg\n Total In:\n 1,220 mL\n 830 mL\n PO:\n 1,220 mL\n 830 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,000 mL\n 300 mL\n Urine:\n 1,000 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 530 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n 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: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: ),\n Egophony\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , 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): ox2, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 12.9 g/dL\n 205 K/uL\n 124 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 38.8 %\n 10.4 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n 04:29 PM\n 03:48 AM\n 05:20 AM\n WBC\n 12.1\n 12.3\n 10.4\n Hct\n 40.9\n 36.3\n 39.9\n 38.8\n Plt\n 223\n 183\n 205\n Cr\n 1.0\n 0.9\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n 124\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 44 yom with developmental delay, esophageal stricture admitted with\n food impaction and pneumonia.\n FOOD IMPACTION -- Esophogeal stricture. s/p EGD with movement of food\n into stomach. No further intervention. Continue PPI. Need to\n determine whether requires dilitation of stricture prior to discharge\n --> check with GI service.\n PNEUMONIA -- likely aspiration in context of esophogeal food\n impaction. Continue antimicrobials, MDIs. Encourage cough.\n HYPOXEMIA -- attributed to pneumonia. Improving. Continue\n supplimental oxygen, maintain SaO2 > 90%. Monitor closely.\n NAUSEA/VOMITTING -- attributed to food impaction, but now improved.\n be contribution of severe cough --> vomiting. Now improving.\n ACUTE RENAL FAIULRE -- likely pre-renal. Improve with hydration.\n ANEMIA -- falling Hct, without clinical evidence for blood loss. \n be dilutional. Monitor serial Hct, guiac stools.\n HYPOTHYROIDISM -- elevated TSH. Will check free T4\n BIPOLAR DISORDER -- continue home meds.\n CROHN'S DISEASE -- continue asacol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\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: Full code\n Disposition : Transfer to medical \n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2133-05-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684475, "text": "Chief Complaint: 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 24 Hour Events:\n Continues to experience cough, somewhat improved.\n Continues with requirement for supplimental oxygen.\n Cough remains, but slowling improving.\n History obtained from Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\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 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: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, 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: 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 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 84 (57 - 91) bpm\n BP: 140/55(127) {114/14(35) - 146/84(127)} mmHg\n RR: 31 (20 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.2 kg (admission): 106.8 kg\n Total In:\n 1,220 mL\n 830 mL\n PO:\n 1,220 mL\n 830 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,000 mL\n 300 mL\n Urine:\n 1,000 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 530 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n 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: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: ),\n Egophony\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , 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): ox2, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 12.9 g/dL\n 205 K/uL\n 124 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 38.8 %\n 10.4 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n 04:29 PM\n 03:48 AM\n 05:20 AM\n WBC\n 12.1\n 12.3\n 10.4\n Hct\n 40.9\n 36.3\n 39.9\n 38.8\n Plt\n 223\n 183\n 205\n Cr\n 1.0\n 0.9\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n 124\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 44 yom with developmental delay, esophageal stricture admitted with\n food impaction and pneumonia.\n FOOD IMPACTION -- Esophogeal stricture. s/p EGD with movement of food\n into stomach. No further intervention. Continue PPI. Need to\n determine whether requires dilitation of stricture prior to discharge\n --> check with GI service.\n PNEUMONIA -- likely aspiration in context of esophogeal food\n impaction. Continue antimicrobials, MDIs. Encourage cough.\n HYPOXEMIA -- attributed to pneumonia. Improving. Continue\n supplimental oxygen, maintain SaO2 > 90%. Monitor closely.\n NAUSEA/VOMITTING -- attributed to food impaction, but now improved.\n be contribution of severe cough --> vomiting. Now improving.\n ACUTE RENAL FAIULRE -- likely pre-renal. Improve with hydration.\n ANEMIA -- falling Hct, without clinical evidence for blood loss. \n be dilutional. Monitor serial Hct, guiac stools.\n HYPOTHYROIDISM -- elevated TSH. Will check free T4\n BIPOLAR DISORDER -- continue home meds.\n CROHN'S DISEASE -- continue asacol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\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: Full code\n Disposition : Transfer to medical \n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683904, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 07:46 PM\n NASAL SWAB - At 08:52 PM\n URINE CULTURE - At 08:52 PM\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 105 (97 - 109) bpm\n BP: 119/69(81) {112/64(76) - 141/122(126)} mmHg\n RR: 32 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 294 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 294 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, well appearing, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. PSYCH: Listens and responds to questions\n appropriately, pleasant\n Peripheral Vascular: strong DP and radial pulses\n Labs / Radiology\n 223 K/uL\n 13.8 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - LFTs mildly elevated, continue to follow\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Awaiting sputum sample for cx\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Decrease levo to 40 mcg q day\n .\n #) Hypothyroidism - Continue levothyroxine at decreased dose.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: PPI, bowel regimen\n VAP:\n Comments:\n Communication: Comments: with patient. /mother\n . /sister . Group home\n , .\n Code status: Full\n Disposition: to floor today if sats stable\n" }, { "category": "Physician ", "chartdate": "2133-05-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 683820, "text": "Chief Complaint: food stuck in throat, fevers, cough\n HPI:\n This is a 44 yo M with h/o developmental delay, hiatal hernia, GE\n junction stricture, esophagitis and Crohn's disease who presents with\n fevers, cough, and a sensation of food stuck in his throat. He was\n eating meat yesterday when he felt it get caught in his throat, which\n resulted in nausea and multiple episodes of non-bloody, non-bilious\n emesis not associated with abdominal pain or diarrhea. Per group home\n staff, pt was noted to swallow his vomit. Due to concern for aspiration\n and new onset of productive cough, he was seen in urgent care clinic\n where he was reportedly diagnosed with a LLL vs. PNA (ED\n documentation unclear) on a CXR and was sent to the ED for evaluation.\n The patient denies fevers, chills. He has had several sick contacts at\n his group home but group home staff deny any H1N1 or influenza cases at\n group home recently.\n .\n In the , pt with low grade fever to 100.1, RR 28, O2 sat 97% 4L NC.\n Labs notable for WBC 15.1 with 83% neutrophils, BUN 21, Cr 1.2, and\n lactate 1.1. CXR revealed low lung volumes without a clear infiltrate\n but possible retrocardiac opacity and neck x-ray did not definitely\n show the presence of any foreign bodies. Given levofloxacin 750 mg IV X\n 1, flagyl 500 mg IV X 1, zofran 4 mg IV X 1, and 1 L IVFs. GI consulted\n who recommended admission to ICU for likely EGD to rule out food\n impaction.\n .\n Upon arrival to the , EGD was performed that showed food\n proximal to a 14 mm esophageal stricture. The food was advanced to the\n stomach, remaining EGD unremarkable.\n .\n ROS as above. Denies dysuria, chest pain. Reports cough and some\n shortness of breath. No rashes, myalgias.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:00 PM\n Fentanyl - 07:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Developmental delay\n Bipolar disorder\n Hypothyroidism\n Hiatal hernia\n GE junction stricture\n Esophagitis\n Crohn's disease\n Anxiety\n unknown\n Occupation: does not work.\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives in group home in .\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: Nausea, Emesis, feels food is stuck in throat\n Musculoskeletal: no myalgias\n Integumentary (skin): no rash\n Flowsheet Data as of 11:39 PM\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: 37.4\nC (99.4\n HR: 105 (101 - 109) bpm\n BP: 126/70(80) {112/64(76) - 141/122(126)} mmHg\n RR: 24 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 636 mL\n PO:\n 240 mL\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 311 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n T 99.4 BP 125/68 HR 109 RR 29 O2 91% on neb\n Gen - mild respiratory distress with mild accecessory muscle use,\n tachypneic, obese male, non-toxic appearing, sleepy but easily\n arousable\n HEENT - no JVD appreciated, supple\n CV - tachycardic, no m/r/g appreciated\n Lungs - bilataral coase upper airway breath sounds with diffuse\n scattered wheezes and rhonchi throughout, no crackles\n Abd - Soft, obese, NT, ND, normoactive BS\n Ext - no LE edema, WWP\n Skin - no rashes or lesions\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers thus\n far in ED. CXR at urgent care center reportedly with LLL vs. PNA\n (unclear from documentation) although CXR in ED read as no clear\n infiltrate although there appears to be presence of a retrocardiac\n opacity. It is possible that leukocytosis may be secondary to\n aspiration pnuemonitis rather than actual aspiration PNA or CAP. No\n other clear localizing signs or symptoms other episodes of nausea and\n vomiting yesterday that was in association with ? food impaction.\n Lactate not elevated.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - Add on LFTs.\n - Check UA.\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Obtain sputum cx.\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF - Baseline Cr 0.8 - 1.0, Cr on admission 1.2 with elevated BUN\n 21. Likely due to prerenal etiology given innumberable episodes of\n emesis prior to admission. s/p 1 L IVFs in ED.\n - Give additional 1L IVFs overnight.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Will check TSH to ensure pt not being overreplaced with\n levothyroxine.\n .\n #) Hypothyroidism - Continue levothyroxine.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n .\n #) FEN/GI - NPO for now given\n #) Ppx - heparin SQ, bowel regimen, PPI\n #) Code - full\n #) Communication - with patient. /mother . \n /sister . Group home , .\n #) Access - PIV\n #) Dispo - likely callout to floor after EGD\n ICU Care\n Nutrition: regular diet\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU, possible c/o to floor in am\n" }, { "category": "Physician ", "chartdate": "2133-05-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 683821, "text": "Chief Complaint: food stuck in throat, fevers, cough\n HPI:\n This is a 44 yo M with h/o developmental delay, hiatal hernia, GE\n junction stricture, esophagitis and Crohn's disease who presents with\n fevers, cough, and a sensation of food stuck in his throat. He was\n eating meat yesterday when he felt it get caught in his throat, which\n resulted in nausea and multiple episodes of non-bloody, non-bilious\n emesis not associated with abdominal pain or diarrhea. Per group home\n staff, pt was noted to swallow his vomit. Due to concern for aspiration\n and new onset of productive cough, he was seen in urgent care clinic\n where he was reportedly diagnosed with a LLL vs. PNA (ED\n documentation unclear) on a CXR and was sent to the ED for evaluation.\n The patient denies fevers, chills. He has had several sick contacts at\n his group home but group home staff deny any H1N1 or influenza cases at\n group home recently.\n .\n In the , pt with low grade fever to 100.1, RR 28, O2 sat 97% 4L NC.\n Labs notable for WBC 15.1 with 83% neutrophils, BUN 21, Cr 1.2, and\n lactate 1.1. CXR revealed low lung volumes without a clear infiltrate\n but possible retrocardiac opacity and neck x-ray did not definitely\n show the presence of any foreign bodies. Given levofloxacin 750 mg IV X\n 1, flagyl 500 mg IV X 1, zofran 4 mg IV X 1, and 1 L IVFs. GI consulted\n who recommended admission to ICU for likely EGD to rule out food\n impaction.\n .\n Upon arrival to the , EGD was performed that showed food\n proximal to a 14 mm esophageal stricture. The food was advanced to the\n stomach, remaining EGD unremarkable.\n .\n ROS as above. Denies dysuria, chest pain. Reports cough and some\n shortness of breath. No rashes, myalgias.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:00 PM\n Fentanyl - 07:00 PM\n Other medications:\n Advair 100/50 1 puff --> recently d/c'd per NH staff\n Asacol 800 mg tid\n Desonide 0.05% to face at bedtime\n Divalproex 1000 mg tid\n Fluoxetine 40 mg daily\n Dulcolax 10 mg qhs prn\n Albuterol 2 puffs q2h prn\n Tylenol 625 mg q4h prn\n Cetaphil lotion\n Diazepam 10 mg 1 hr prior to dental procedures\n Benadryl 25 mg prn for itching/rash\n Guaifenesin 15 cc q6h prn for cough\n Kaopectate 15 cc q6h prn for diarrhea or loose stools\n Ketoconazole\n Levothyroxine 50 mcg daily\n Milk of magnesia prn\n Neutrogena T Gel\n Omeprazole 40 mg daily\n Zyprexa 30 mg qhs\n Past medical history:\n Family history:\n Social History:\n Developmental delay\n Bipolar disorder\n Hypothyroidism\n Hiatal hernia\n GE junction stricture\n Esophagitis\n Crohn's disease\n Anxiety\n unknown\n Occupation: does not work.\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives in group home in .\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: Nausea, Emesis, feels food is stuck in throat\n Musculoskeletal: no myalgias\n Integumentary (skin): no rash\n Flowsheet Data as of 11:39 PM\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: 37.4\nC (99.4\n HR: 105 (101 - 109) bpm\n BP: 126/70(80) {112/64(76) - 141/122(126)} mmHg\n RR: 24 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 636 mL\n PO:\n 240 mL\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 311 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n T 99.4 BP 125/68 HR 109 RR 29 O2 91% on neb\n Gen - mild respiratory distress with mild accecessory muscle use,\n tachypneic, obese male, non-toxic appearing, sleepy but easily\n arousable\n HEENT - no JVD appreciated, supple\n CV - tachycardic, no m/r/g appreciated\n Lungs - bilataral coase upper airway breath sounds with diffuse\n scattered wheezes and rhonchi throughout, no crackles\n Abd - Soft, obese, NT, ND, normoactive BS\n Ext - no LE edema, WWP\n Skin - no rashes or lesions\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers thus\n far in ED. CXR at urgent care center reportedly with LLL vs. PNA\n (unclear from documentation) although CXR in ED read as no clear\n infiltrate although there appears to be presence of a retrocardiac\n opacity. It is possible that leukocytosis may be secondary to\n aspiration pnuemonitis rather than actual aspiration PNA or CAP. No\n other clear localizing signs or symptoms other episodes of nausea and\n vomiting yesterday that was in association with ? food impaction.\n Lactate not elevated.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - Add on LFTs.\n - Check UA.\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Obtain sputum cx.\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF - Baseline Cr 0.8 - 1.0, Cr on admission 1.2 with elevated BUN\n 21. Likely due to prerenal etiology given innumberable episodes of\n emesis prior to admission. s/p 1 L IVFs in ED.\n - Give additional 1L IVFs overnight.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Will check TSH to ensure pt not being overreplaced with\n levothyroxine.\n .\n #) Hypothyroidism - Continue levothyroxine.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n .\n #) FEN/GI - NPO for now given\n #) Ppx - heparin SQ, bowel regimen, PPI\n #) Code - full\n #) Communication - with patient. /mother . \n /sister . Group home , .\n #) Access - PIV\n #) Dispo - likely callout to floor after EGD\n ICU Care\n Nutrition: regular diet\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU, possible c/o to floor in am\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 683827, "text": "Chief Complaint: food stuck in throat, fevers, cough\n HPI:\n This is a 44 yo M with h/o developmental delay, hiatal hernia, GE\n junction stricture, esophagitis and Crohn's disease who presents with\n fevers, cough, and a sensation of food stuck in his throat. He was\n eating meat yesterday when he felt it get caught in his throat, which\n resulted in nausea and multiple episodes of non-bloody, non-bilious\n emesis not associated with abdominal pain or diarrhea. Per group home\n staff, pt was noted to swallow his vomit. Due to concern for aspiration\n and new onset of productive cough, he was seen in urgent care clinic\n where he was reportedly diagnosed with a LLL vs. PNA (ED\n documentation unclear) on a CXR and was sent to the ED for evaluation.\n The patient denies fevers, chills. He has had several sick contacts at\n his group home but group home staff deny any H1N1 or influenza cases at\n group home recently.\n .\n In the , pt with low grade fever to 100.1, RR 28, O2 sat 97% 4L NC.\n Labs notable for WBC 15.1 with 83% neutrophils, BUN 21, Cr 1.2, and\n lactate 1.1. CXR revealed low lung volumes without a clear infiltrate\n but possible retrocardiac opacity and neck x-ray did not definitely\n show the presence of any foreign bodies. Given levofloxacin 750 mg IV X\n 1, flagyl 500 mg IV X 1, zofran 4 mg IV X 1, and 1 L IVFs. GI consulted\n who recommended admission to ICU for likely EGD to rule out food\n impaction.\n .\n Upon arrival to the , EGD was performed that showed food\n proximal to a 14 mm esophageal stricture. The food was advanced to the\n stomach, remaining EGD unremarkable.\n .\n ROS as above. Denies dysuria, chest pain. Reports cough and some\n shortness of breath. No rashes, myalgias.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:00 PM\n Fentanyl - 07:00 PM\n Other medications:\n Advair 100/50 1 puff --> recently d/c'd per NH staff\n Asacol 800 mg tid\n Desonide 0.05% to face at bedtime\n Divalproex 1000 mg tid\n Fluoxetine 40 mg daily\n Dulcolax 10 mg qhs prn\n Albuterol 2 puffs q2h prn\n Tylenol 625 mg q4h prn\n Cetaphil lotion\n Diazepam 10 mg 1 hr prior to dental procedures\n Benadryl 25 mg prn for itching/rash\n Guaifenesin 15 cc q6h prn for cough\n Kaopectate 15 cc q6h prn for diarrhea or loose stools\n Ketoconazole\n Levothyroxine 50 mcg daily\n Milk of magnesia prn\n Neutrogena T Gel\n Omeprazole 40 mg daily\n Zyprexa 30 mg qhs\n Past medical history:\n Family history:\n Social History:\n Developmental delay\n Bipolar disorder\n Hypothyroidism\n Hiatal hernia\n GE junction stricture\n Esophagitis\n Crohn's disease\n Anxiety\n unknown\n Occupation: does not work.\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives in group home in .\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: Nausea, Emesis, feels food is stuck in throat\n Musculoskeletal: no myalgias\n Integumentary (skin): no rash\n Flowsheet Data as of 11:39 PM\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: 37.4\nC (99.4\n HR: 105 (101 - 109) bpm\n BP: 126/70(80) {112/64(76) - 141/122(126)} mmHg\n RR: 24 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 636 mL\n PO:\n 240 mL\n TF:\n IVF:\n 396 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 311 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n T 99.4 BP 125/68 HR 109 RR 29 O2 91% on neb\n Gen - mild respiratory distress with mild accecessory muscle use,\n tachypneic, obese male, non-toxic appearing, sleepy but easily\n arousable\n HEENT - no JVD appreciated, supple\n CV - tachycardic, no m/r/g appreciated\n Lungs - bilataral coase upper airway breath sounds with diffuse\n scattered wheezes and rhonchi throughout, no crackles\n Abd - Soft, obese, NT, ND, normoactive BS\n Ext - no LE edema, WWP\n Skin - no rashes or lesions\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers thus\n far in ED. CXR at urgent care center reportedly with LLL vs. PNA\n (unclear from documentation) although CXR in ED read as no clear\n infiltrate although there appears to be presence of a retrocardiac\n opacity. It is possible that leukocytosis may be secondary to\n aspiration pnuemonitis rather than actual aspiration PNA or CAP. No\n other clear localizing signs or symptoms other episodes of nausea and\n vomiting yesterday that was in association with ? food impaction.\n Lactate not elevated.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - Add on LFTs.\n - Check UA.\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Obtain sputum cx.\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF - Baseline Cr 0.8 - 1.0, Cr on admission 1.2 with elevated BUN\n 21. Likely due to prerenal etiology given innumberable episodes of\n emesis prior to admission. s/p 1 L IVFs in ED.\n - Give additional 1L IVFs overnight.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Will check TSH to ensure pt not being overreplaced with\n levothyroxine.\n .\n #) Hypothyroidism - Continue levothyroxine.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n .\n #) FEN/GI - NPO for now given\n #) Ppx - heparin SQ, bowel regimen, PPI\n #) Code - full\n #) Communication - with patient. /mother . \n /sister . Group home , .\n #) Access - PIV\n #) Dispo - likely callout to floor after EGD\n ICU Care\n Nutrition: regular diet\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU, possible c/o to floor in am\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 683828, "text": "Chief Complaint: food aspiration\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 44 yo male with devd. delay, gastroesphageal stricture, HH admitted\n with sensatio of food stuck in his throat.\n Yesterday while eating, felt a piece of meat get stuck in his throat.\n He had multiple episodes of nasuea and vomiting. Overnight, he\n continued to vomit with swallowing of vomit. By the next morning, he\n had fevers and was taken to an urgent care clinic with infiltrate on\n CXR. Multiple members at the group home have been sick recently, but no\n known H1N1. Pt denies myalgia's.\n In the ED, Temp was 100.1, pt tachypenic to 28 , sats 97% 4l. WBC 15,\n lactate normal.\n Given LVQ, flagyl for aspiration.\n Neck X ray without foreign body visualized.\n GI consulted for concern of food impaction\n Transferred to ICU\n EGD: piece of meat (3 x 2 cm) next to esophageal stricture- 14mm in\n size, 10 mm long. Meat was pushed into the stomach with subjective\n improvement.\n Post-EGD- ++secretions and rhonchorous, desats to 88% 4 liters n.c.\n Patient admitted from: ER\n History obtained from Medical records, ICU housestaff\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:00 PM\n Fentanyl - 07:00 PM\n Other medications:\n Zyprexa 30 mg, dulcolax, fluoxetine, depakote 1000mg tid, asacol 800 mg\n TID, cough syrup, levothyroxine, albuterol inhaler, Advair (recently\n dc'd)\n Past medical history:\n Family history:\n Social History:\n Developmental delay\n HH\n GE junction stricture\n bipolar d/o\n Anxiety\n Esophagitis\n Crohn's disease, inactive on asacol\n ?Asthma\n \n pt unable to provide\n Occupation:\n Drugs:\n Tobacco: no\n Alcohol:\n Other: Live in group home in \n Review of systems:\n Constitutional: No(t) Fatigue, Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\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: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n 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, History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Delirious, No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 12:28 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: 37.4\nC (99.4\n HR: 102 (101 - 109) bpm\n BP: 132/71(86) {112/64(76) - 141/122(126)} mmHg\n RR: 31 (24 - 36) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 5 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 5 mL\n Blood products:\n Total out:\n 325 mL\n 0 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n 8 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, tachypneic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic),\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: Bronchial:\n , Wheezes : , Diminished: decreased at bases, Rhonchorous: diffuse),\n dark brown secretions suctioned\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Normal\n Labs / Radiology\n 283\n 43.1\n 111\n 1.2\n 21\n 26\n 104\n 4.3\n 142\n 15.1\n [image002.jpg]\n Other labs: ALT / AST:53/44, Alk Phos / T Bili:117/0.8,\n Differential-Neuts:82.8, Lymph:8, Mono:8, Lactic Acid:1.8\n Fluid analysis / Other labs: TSH 7.7\n Imaging: CXR (viewed) mild retrocardic infiltrate\n Assessment and Plan\n 44 yo male with dev. delay, esophageal stricture admitted with food\n impaction, fevers/cough\n 1. Food impaction - s/p EGD with movement of food\n Per GI, no need for additional intervention. On PPI\n Pt will be educated abt taking smaller bites\n 2. Hypoxia/respiratory distress- has new oxygen requirement and given\n circumstances, is a set-up for aspiration\n On levaquin/flagyl, alb nebs, oxygen\n 3. N/V- presumptively due to food impaction but will check LFT's\n 4. ARF- likely pre-renal. Hydrating with IVF and will trend creatinine\n 5. Hypothyroidism: TSH checked due to tachycardia- actually returned\n elevated. Will check free T4\n 6. Bipolar disorder: on home meds\n 7. Crohn's on asacol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 08:52 PM\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: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683906, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 07:46 PM\n NASAL SWAB - At 08:52 PM\n URINE CULTURE - At 08:52 PM\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 105 (97 - 109) bpm\n BP: 119/69(81) {112/64(76) - 141/122(126)} mmHg\n RR: 32 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 294 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 294 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, well appearing, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD.\n CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. PSYCH: Listens and responds to questions\n appropriately, pleasant\n Peripheral Vascular: strong DP and radial pulses\n Labs / Radiology\n 223 K/uL\n 13.8 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - LFTs mildly elevated, continue to follow\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Awaiting sputum sample for cx\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Decrease levo to 40 mcg q day\n .\n #) Hypothyroidism - Continue levothyroxine at decreased dose.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: PPI, bowel regimen\n VAP:\n Comments:\n Communication: Comments: with patient. /mother\n . /sister . Group home\n , .\n Code status: Full\n Disposition: to floor today if sats stable\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683885, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 07:46 PM\n NASAL SWAB - At 08:52 PM\n URINE CULTURE - At 08:52 PM\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 105 (97 - 109) bpm\n BP: 119/69(81) {112/64(76) - 141/122(126)} mmHg\n RR: 32 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 294 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 294 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///28/\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 223 K/uL\n 13.8 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683890, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 07:46 PM\n NASAL SWAB - At 08:52 PM\n URINE CULTURE - At 08:52 PM\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 PM\n Midazolam (Versed) - 07:00 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 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.6\nC (99.7\n HR: 105 (97 - 109) bpm\n BP: 119/69(81) {112/64(76) - 141/122(126)} mmHg\n RR: 32 (24 - 36) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 294 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 294 mL\n Blood products:\n Total out:\n 325 mL\n 400 mL\n Urine:\n 325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///28/\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 223 K/uL\n 13.8 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 40.9 %\n 12.1 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 12.1\n Hct\n 40.9\n Plt\n 223\n Cr\n 1.0\n Glucose\n 116\n Other labs: Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - Follow LFT\n - UA\n - Trend fever curve, tylenol prn.\n - f/u blood cxs.\n - Obtain sputum cx.\n .\n #) Hypoxia - Likely secondary to possible arpisation PNA. Pt also\n diffusely wheezy and rhonchorus post EGD.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF - Baseline Cr 0.8 - 1.0, Cr on admission 1.2 with elevated BUN\n 21. Likely due to prerenal etiology given innumberable episodes of\n emesis prior to admission. s/p 1 L IVFs in ED.\n - Give additional 1L IVFs overnight.\n - Trend BUN, Cr.\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n - IVFs as above.\n - Monitor on telemetry overnight.\n - Will check TSH to ensure pt not being overreplaced with\n levothyroxine.\n .\n #) Hypothyroidism - Continue levothyroxine.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD\n today.\n .\n #) Crohn's disease - Not active. Continue asacol.\n .\n #) FEN/GI - NPO for now given\n #) Ppx - heparin SQ, bowel regimen, PPI\n #) Code - full\n #) Communication - with patient. /mother . \n /sister . Group home , .\n #) Access - PIV\n #) Dispo - likely callout to floor after EGD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-05-23 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 683897, "text": "Chief Complaint: food aspiration\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 44 yo male with devd. delay, gastroesphageal stricture, HH admitted\n with sensatio of food stuck in his throat.\n Yesterday while eating, felt a piece of meat get stuck in his throat.\n He had multiple episodes of nasuea and vomiting. Overnight, he\n continued to vomit with swallowing of vomit. By the next morning, he\n had fevers and was taken to an urgent care clinic with infiltrate on\n CXR. Multiple members at the group home have been sick recently, but no\n known H1N1. Pt denies myalgia's.\n In the ED, Temp was 100.1, pt tachypenic to 28 , sats 97% 4l. WBC 15,\n lactate normal.\n Given LVQ, flagyl for aspiration.\n Neck X ray without foreign body visualized.\n GI consulted for concern of food impaction\n Transferred to ICU\n EGD: piece of meat (3 x 2 cm) next to esophageal stricture- 14mm in\n size, 10 mm long. Meat was pushed into the stomach with subjective\n improvement.\n Post-EGD- ++secretions and rhonchorous, desats to 88% 4 liters n.c.\n Patient admitted from: ER\n History obtained from Medical records, ICU housestaff\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 07:00 PM\n Fentanyl - 07:00 PM\n Other medications:\n Zyprexa 30 mg, dulcolax, fluoxetine, depakote 1000mg tid, asacol 800 mg\n TID, cough syrup, levothyroxine, albuterol inhaler, Advair (recently\n dc'd)\n Past medical history:\n Family history:\n Social History:\n Developmental delay\n HH\n GE junction stricture\n bipolar d/o\n Anxiety\n Esophagitis\n Crohn's disease, inactive on asacol\n ?Asthma\n \n pt unable to provide\n Occupation:\n Drugs:\n Tobacco: no\n Alcohol:\n Other: Live in group home in \n Review of systems:\n Constitutional: No(t) Fatigue, Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\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: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n 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, History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Delirious, No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 12:28 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: 37.4\nC (99.4\n HR: 102 (101 - 109) bpm\n BP: 132/71(86) {112/64(76) - 141/122(126)} mmHg\n RR: 31 (24 - 36) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,340 mL\n 5 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,100 mL\n 5 mL\n Blood products:\n Total out:\n 325 mL\n 0 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,015 mL\n 8 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, tachypneic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic),\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: Bronchial:\n , Wheezes : , Diminished: decreased at bases, Rhonchorous: diffuse),\n dark brown secretions suctioned\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, Tone: Normal\n Labs / Radiology\n 283\n 43.1\n 111\n 1.2\n 21\n 26\n 104\n 4.3\n 142\n 15.1\n [image002.jpg]\n Other labs: ALT / AST:53/44, Alk Phos / T Bili:117/0.8,\n Differential-Neuts:82.8, Lymph:8, Mono:8, Lactic Acid:1.8\n Fluid analysis / Other labs: TSH 7.7\n Imaging: CXR (viewed) mild retrocardic infiltrate\n Assessment and Plan\n 44 yo male with dev. delay, esophageal stricture admitted with food\n impaction, fevers/cough\n 1. Food impaction - s/p EGD with movement of food\n Per GI, no need for additional intervention. On PPI\n Pt will be educated abt taking smaller bites\n 2. Hypoxia/respiratory distress- has new oxygen requirement and given\n circumstances, is a set-up for aspiration with infiltrates on CXR\n On levaquin/flagyl, alb nebs, oxygen\n 3. N/V- presumptively due to food impaction but will check LFT's\n 4. ARF- likely pre-renal. Hydrating with IVF and will trend creatinine\n 5. Hypothyroidism: TSH checked due to tachycardia- actually returned\n elevated. Will check free T4\n 6. Bipolar disorder: on home meds\n 7. Crohn's on asacol\n Rest of plan as per ICU resident\ns note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 08:52 PM\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: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2133-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684032, "text": "44 y/o M with a PMH significant for asthma, developmental delay, hiatal\n hernia, gastro esophogeal stricture, esophagitis and Crohn's disease,\n who presented to the ED complaining of N/V and a sensation of food\n stuck in his throat. CXR inidicative of LLL PNA possibly to\n aspiration and he was started on levoquin/flagyl and admitted to the\n M/SICU for an EGD and monitoring.\n Hypoxemia\n Assessment:\n Patient with LLL PNA\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684223, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Reports emesis after dinner yesterday but tolerating full diet this\n morning\n Ambulating with aid of PT, desaturates to low 90s on NC\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:15 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 88 (85 - 116) bpm\n BP: 125/67(81) {109/55(75) - 141/81(91)} mmHg\n RR: 30 (27 - 43) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n PO:\n 1,690 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\n Physical Examination\n General: moderately obese, alert, pleasant\n HEENT: EOMI, PERRL, oropharynx clear\n CV: RRR S1S2, no murmurs auscultated\n Resp: diffuse rhonchi and crackles, improvement with coughing, shallow\n breaths with poor air entry\n Abd: obese, soft/ NT/ ND +BS\n Ext: +2 DP\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs, sputum cxs\n .\n #) Hypoxia - Likely secondary to possible aspiration PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n - Bolus 1 L NS\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n .\n #) Hypothyroidism\n Elevated TSH, consider decreasing levothyroxine on\n dc.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684234, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Reports emesis after dinner yesterday but tolerating full diet this\n morning\n Ambulating with aid of PT, desaturates to low 90s on NC\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:15 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 88 (85 - 116) bpm\n BP: 125/67(81) {109/55(75) - 141/81(91)} mmHg\n RR: 30 (27 - 43) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n PO:\n 1,690 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\n Physical Examination\n General: moderately obese, alert, pleasant\n HEENT: EOMI, PERRL, oropharynx clear\n CV: RRR S1S2, no murmurs auscultated\n Resp: diffuse rhonchi and crackles, improvement with coughing, shallow\n breaths with poor air entry, +egophany\n Abd: obese, soft/ NT/ ND +BS\n Ext: +2 DP\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n Patient able to tolerate regular diet\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI\n .\n #) Aspiration Pneumonia: Patient present with hypoxia, leukocytosis,\n and consolidation on CXR following episode of food impaction\n - pulmonary status improving: WBC count trending downwards, afebrile,\n decreasing oxygen requirements\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - f/u blood cxs, sputum cxs\n -cont. to wean O2 as tolerated, nebs PRN\n -encourage pulmonary toilet with incentive spirometry, elevation of\n head of bed\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n .\n #) Hypothyroidism\n Elevated TSH to 7.7, consider increasing\n levothyroxine on d/c.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis\n esophageal stricture and hiatal hernia as seen on EGD\n - Continue PPI. No active signs of active esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT: pneumo boots, encourage ambulation\n Stress ulcer: on PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: stable\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684290, "text": "Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684291, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 90-91%, RR 26-40\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow/brownish secretions. Pm blood gas\n 7.42/41/65/1/28, MD aware, wants continue monitor O2 sats >90%\n Action:\n Continued O2 4L nasal canula and 50% face tent, encouraged deep\n breathing and cough exercises, nebs given. sputum culture sent\n Response:\n Stable overnight, RR 30-40\ns, slept well, WBC 12.3, continue to have\n low grade temp\n Plan:\n Continue wean O2 as tolerated, continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2133-05-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684348, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 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 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 132/14(35) {114/14(35) - 146/84(146)} mmHg\n RR: 23 (20 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,220 mL\n 350 mL\n PO:\n 1,220 mL\n 350 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\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 205 K/uL\n 12.9 g/dL\n 124 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 38.8 %\n 10.4 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n 04:29 PM\n 03:48 AM\n 05:20 AM\n WBC\n 12.1\n 12.3\n 10.4\n Hct\n 40.9\n 36.3\n 39.9\n 38.8\n Plt\n 223\n 183\n 205\n Cr\n 1.0\n 0.9\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n 124\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n POSTURE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n Patient able to tolerate regular diet\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI\n .\n #) Aspiration Pneumonia: Patient present with hypoxia, leukocytosis,\n and consolidation on CXR following episode of food impaction\n - pulmonary status improving: WBC count trending downwards, afebrile,\n decreasing oxygen requirements\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - f/u blood cxs, sputum cxs\n -cont. to wean O2 as tolerated, nebs PRN\n -encourage pulmonary toilet with incentive spirometry, elevation of\n head of bed\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n .\n #) Hypothyroidism\n Elevated TSH to 7.7, consider increasing\n levothyroxine on d/c.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis\n esophageal stricture and hiatal hernia as seen on EGD\n - Continue PPI. No active signs of active esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-05-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684454, "text": "TITLE:\n Chief Complaint: respiratory distress,\nsomething stuck in throat\n 24 Hour Events:\n -O2 sats stable\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 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 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 132/14(35) {114/14(35) - 146/84(146)} mmHg\n RR: 23 (20 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,220 mL\n 350 mL\n PO:\n 1,220 mL\n 350 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97% on 6.5 L\n ABG: ///26/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Pleasant, well appearing,in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: Rhonchorous throughout\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 205 K/uL\n 12.9 g/dL\n 124 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 105 mEq/L\n 141 mEq/L\n 38.8 %\n 10.4 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n 04:29 PM\n 03:48 AM\n 05:20 AM\n WBC\n 12.1\n 12.3\n 10.4\n Hct\n 40.9\n 36.3\n 39.9\n 38.8\n Plt\n 223\n 183\n 205\n Cr\n 1.0\n 0.9\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n 124\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n POSTURE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Aspiration Pneumonia: Patient present with hypoxia, leukocytosis,\n and consolidation on CXR following episode of food impaction. Pt sats\n in low 90s with NC removed\n - pulmonary status improving: WBC count trending downwards, afebrile,\n decreasing oxygen requirements\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - f/u blood cxs, sputum cxs\n -cont. to wean O2 as tolerated, nebs PRN\n -encourage pulmonary toilet with incentive spirometry, elevation of\n head of bed\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n Patient able to tolerate regular diet.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI\n .\n #) ARF\n Creatinine continues to improve. Likely due to prerenal\n etiology given innumberable episodes of emesis prior to admission. -\n Trend BUN, Cr.\n .\n #) Hypothyroidism\n Elevated TSH to 7.7, consider increasing\n levothyroxine on d/c.\n .\n #Transaminitis: elevated at baseline, improved since admission.\n Suspect medication-related. Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter if needed.\n .\n #) Esophagitis\n esophageal stricture and hiatal hernia as seen on EGD\n - Continue PPI. No active signs of active esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition: PO\n Glycemic Control: n/a\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: omeprazole\n VAP:\n Comments:\n Communication: Comments: /mother . \n /sister . Group home , .\n Code status: Full\n Disposition: To floor today\n" }, { "category": "Rehab Services", "chartdate": "2133-05-24 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 684187, "text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: aspiration pna / 482.9\n Reason of referral: CPT\n History of Present Illness / Subjective Complaint: Pt is 44M with\n developmental delay admitted from group home with fever, cough\n and sensation of food caught in his throat. On EGD pt found to have\n food proximal to esophageal stricture; food was advanced into stomach.\n Pt demonstarting hypoxia on RA and leukocytosis likely aspiration\n pna. Pt currently requiring supplement O2.\n Past Medical / Surgical History: developmental delay, bipolar d/o,\n hypothyroidism, hiatal hernia, GE junction stricture, esophagitis,\n Crohn's disease, anxiety\n Medications: acetaminophen, levofloxacin, flagyl, heparin\n Radiology: CXR: report unavailable\n Labs:\n 36.3\n 12.5\n 183\n 12.3\n [image002.jpg]\n Other labs:\n ABGs :\n pH: 7.42\n pCO2: 41\n pO2: 65\n HCO3: 28\n Activity Orders: OOB with assist\n Social / Occupational History: pt lives in group home, supportive\n mother, developmental delay\n Living Environment: unable to determine if there are stairs present in\n group home\n Prior Functional Status / Activity Level: I amb without AD, minor A\n with self ADLs per information from group home, pt enjoys watching TV,\n going on outings and eating\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt sleeping on arrival\n into room, but pt easily arousable. Pt answers all questions\n appropriately and follows multi-step commands. Pt pleasant and\n cooperative.\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 76\n 120/67\n 28\n 94% on 6L NC\n Rest\n /\n Sit\n 90\n 121/79\n 32\n 92% on 2L NC\n Activity\n 124\n /\n 42\n 88-90% on 6L NC\n Stand\n /\n Recovery\n 92\n 118/71\n 32\n 94% on 6L NC + face mask\n Total distance walked: 125ft\n Minutes:\n Pulmonary Status: BS rhonchorous t/o lungs; shallow breathing pattern;\n strong cough productive for ~3 tablespoons white/yellow sputum with\n position changes and s/p amb; IS 250-500mL x6 (pt requires verbal cues\n with use of IS)\n Integumentary / Vascular: skin intact where visible, all extremities\n warm to touch\n Sensory Integrity: pt denies parasthesias\n Pain / Limiting Symptoms: pt reports pain in toes with amb, unable to\n rate on numerical pain scale; no obvious deformity observed on toes\n Posture: pt demonstrates posterior pelvic tilt with extreme kyphotic\n curve and flexed cervical spine (chin almost contacting sternum in\n sitting)\n Range of Motion\n Muscle Performance\n WFL t/o all extremities\n B UE and LE grossly t/o\n pt able to extend cervical spine, but is unable to maintain for >10\n seconds\n Motor Function: no abnormal movement patterns observed, pt able to\n manipulate sock to \n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was I with sup>sit EOB. Pt required close S\n sit>stand and required use of hands to push off bed. Pt amb 125ft with\n close S and no AD. Pt demonstrates wide BOS and decreased step length,\n push off and heel strike. Pt steady with amb, but limited by SOB,\n fatigue and pain in toes.\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: sitting: I sit EOB unsupported, able to reach min outside BOS\n standing: close S stand unsupported\n amb: no major/minor LOB without AD\n Education / Communication: Pt: PT role, PT plan of care, pulmonary\n hygiene, deep breathing techniques/use of IS (pt requires max VCs),\n mobility techniques\n NSG: pt status, O2 sats, no need for CPT but encourage amb and coughing\n Intervention:\n Other: pt left sitting in chair, monitors on, call light in reach, NSG\n aware\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Airway Clearance, Impaired\n 3.\n Posture, Impaired\n 4.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: Pt is 44M admitted with aspiration pna\n and esophageal food obstruction p/w above impairments c/w air clearance\n dysfunction and deconditioning of postural muscles. Pt has potential\n to return to I amb and increase endurance with further daily activity\n and encouragement to cough to clear secretions; due to age, prior level\n of function and medical management of pna. Pt will benefit from\n continued PT f/u to progress endurance, pulmonary hygiene and O2\n weaning with activity. Pt currently not appropriate for CPT due to\n pt's ability to amb and productive cough, recommend amb multiple\n times/day and encouragement to cough. Anticipate pt will be safe for\n d/c to group home in additional PT visits with resolution of\n hypoxia.\n Goals\n Time frame: 1 week\n 1.\n I amb 300ft without AD\n 2.\n IS >1000mL x4 with mod VCs\n 3.\n I coughing/clear secretions\n 4.\n above with O2 sats >92% on RA\n 5.\n tolerate upright posture for 1 min with deep breathing exercises\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 4-6x/week for 1 week\n endurance training\n pulmonary hygiene\n postural exercise/education\n deep breathing techniques/use of IS\n O2 weaning\n pt/family ed\n D/C planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n 8:30-9:17\n" }, { "category": "Nursing", "chartdate": "2133-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684086, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 90-91%, RR 26-40\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow/brownish secretions. Pm blood gas\n Action:\n Continued O2 4L nasal canula and 50% face tent, encouraged deep\n breathing and cough exercises, nebs given. sputum culture sent\n Response:\n Plan:\n Continue wean O2 as tolerated, continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684201, "text": "Chief Complaint: 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 24 Hour Events:\n No further choking episodes.\n Tolerating regular diet.\n Experienced decreased SaO2 last PM, resolved with increased FiO2.\n Experienced emesis following eating last PM, but no emesis experienced\n after breakfast this AM.\n History obtained from Medical records\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 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: Cough, No(t) Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Emesis, No(t)\n 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 12:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.5\nC (99.5\n HR: 86 (80 - 116) bpm\n BP: 134/68(146) {119/55(75) - 141/81(146)} mmHg\n RR: 30 (26 - 42) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n 360 mL\n PO:\n 1,690 mL\n 360 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 700 mL\n Urine:\n 1,000 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 95%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: 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, 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: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: ),\n Egophony at left base\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 183 K/uL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 44 yom with developmental delay, esophageal stricture admitted with\n food impaction and pneumonia.\n FOOD IMPACTION -- Esophogeal stricture. s/p EGD with movement of food\n into stomach. No further intervention. Continue PPI. Need to\n determine whether requires dilitation of stricture prior to discharge\n --> check with GI service.\n PNEUMONIA -- likely aspiration in context of esophogeal food\n impaction. Continue antimicrobials, MDIs. Encourage cough.\n HYPOXEMIA -- attributed to pneumonia. Continue supplimental oxygen,\n maintain SaO2 > 90%. Monitor closely.\n NAUSEA/VOMMITTING -- attributed to food impaction, but now improved.\n be contribution of severe cough --> vomiting. Now improving.\n ACUTE RENAL FAIULRE -- likely pre-renal. Improve with hydration.\n ANEMIA -- falling Hct, without clinical evidence for blood loss. \n be dilutional. Monitor serial Hct, guiac stools.\n HYPOTHYROIDISM -- elevated TSH. Will check free T4\n BIPOLAR DISORDER -- continue home meds.\n CROHN'S DISEASE -- continue asacol\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\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: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2133-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684330, "text": "44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n Hypoxemia\n Assessment:\n Hypoxia, likely secondary to possible aspiration PNA, received patient\n on 4L nasal canula, and O2 sats 90-91%, RR 26-30\ns, patient appears to\n be comfortable, no SOB or resp distress. Patient got cough and\n expectorating thick yellow secretions.\n Action:\n Continued O2 4L nasal canula and encouraged deep breathing and cough\n exercises, nebs given.\n Response:\n Stable overnight, O2 sats >90%, slept well\n Plan:\n Continue wean O2 as tolerated; continue antibiotics, F/U culture\n results, encourage deep breathing and cough, nebs. ? c/o to floor\n" }, { "category": "Physician ", "chartdate": "2133-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684170, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Reports emesis after PO intake\n Desaturates to SaO2 easily requiring adjustment of O2 NC\n Allergies:\n Klonopin (Oral) (Clonazepam)\n Unknown;\n Penicillins\n Unknown;\n Clozaril (Oral) (Clozapine)\n seizure;\n Latex\n Rash;\n Food Extracts\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:15 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 88 (85 - 116) bpm\n BP: 125/67(81) {109/55(75) - 141/81(91)} mmHg\n RR: 30 (27 - 43) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,090 mL\n PO:\n 1,690 mL\n TF:\n IVF:\n 1,400 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 96%\n ABG: 7.42/41/65/25/1\n PaO2 / FiO2: 163\n Physical Examination\n General: moderately obese, alert, pleasant\n HEENT: EOMI, PERRL, oropharynx clear\n CV: RRR S1S2, no murmurs auscultated\n Resp: diffuse rhonchi clear with coughing, shallow breaths with poor\n air entry\n Abd:\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 36.3 %\n 12.3 K/uL\n [image002.jpg]\n 05:09 AM\n 03:57 PM\n 04:25 AM\n WBC\n 12.1\n 12.3\n Hct\n 40.9\n 36.3\n Plt\n 223\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 28\n Glucose\n 116\n 119\n Other labs: ALT / AST:29/28, Alk Phos / T Bili:92/0.7, LDH:187 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPOXEMIA\n 44 y M with h/o developmental delay, obesity who presents with fevers,\n cough, and possible food impaction.\n .\n #) Food impaction - s/p EGD that revealed food in above 14 mm\n esophageal stricture. Does have predisposition for food impaction\n including h/o GE junction stricture, esophagitis, and hiatal hernia.\n Per GI, esophagel stricture does not require further intervention.\n - Educate pt regarding chewing food carefully and cutting food into\n small pieces before swallowing.\n - Continue PPI.\n .\n #) Leukocytosis - WBC elevated to 15.1 without bandemia. No fevers\n while in ICU. With retrocardiac opacity on CXR, concern for CAP vs\n aspiration PNA, vs aspiration pneumonitis. Pt denies any\n symptomatology of GI infection or UTI. He did have several episodes of\n emesis prior to admission, however this was likely caused by food\n impaction as he has not had any further episodes. Lactate not\n elevated, pressures stable.\n - Continue levofloxacin, flagyl for likely aspiration PNA.\n - UA pending\n - Trend fever curve, tylenol prn.\n - f/u blood cxs, sputum cxs\n .\n #) Hypoxia - Likely secondary to possible aspiration PNA. Pt also\n diffusely wheezy and rhonchorus post EGD. Pt tends to desat while\n sleeping and may have a component of OSA. Currently on 6 L NC.\n - Wean O2 as tolerated.\n - Treating for likely aspiration PNA as above.\n - Nebs prn\n .\n #) ARF\n Creatinine improved with 1L bolus fluids o/n. Likely due to\n prerenal etiology given innumberable episodes of emesis prior to\n admission. s/p 1 L IVFs in ED.\n - Trend BUN, Cr.\n - Bolus 1 L NS\n .\n #) Tachycardia - Likely dehydration, anxiety, pain s/p procedure.\n TSH 7.7.\n - IVFs as above.\n - Monitor on telemetry overnight.\n .\n #) Hypothyroidism\n Elevated TSH, consider decreasing levothyroxine on\n dc.\n .\n #Transaminitis: elevated at baseline. Suspect medication-related.\n Will follow.\n .\n #) Bipolar disorder - Continue depakote, zyprexa, SSRI. Per group home,\n pt can become very aggressive and assaultive and often has verbal\n outbursts. Group home to provide 1:1 sitter overnight. If patient\n needs additional supervision during the day the group home should be\n contact as they may be able to provide a daytime staff member as\n well.\n .\n #) Esophagitis - Continue PPI. No active signs of esophagitis on EGD.\n .\n #) Crohn's disease - Not active. Continue asacol.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2133-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1085806, "text": " 3:44 PM\n CHEST (PA & LAT) Clip # \n Reason: pna? fb?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with recent FB bolus stuck in throat now w/ fever cough and\n sputum dark and foul smelling.\n REASON FOR THIS EXAMINATION:\n pna? fb?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male with fever, cough, dark sputum. Evaluate for\n pneumonia, foreign body.\n\n PA and lateral chest radiographs interpreted without comparison lung\n volumes and bibasilar opacities. The heart is poorly assessed. There is no\n pneumothorax or pleural effusion.\n\n IMPRESSION: Bibasilar opacities, which given history of foreign body bolus in\n throat, may represent aspiration or aspiration pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085982, "text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with likely aspiration pneumonia and new oxygen requirement\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 44-year-old male with likely aspiration pneumonia with new oxygen\n requirement. Evaluate for interval change.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is again seen bibasilar infiltrates some of which may represent\n atelectasis particularly on the left side. There are low lung volumes.\n Overall, there is no appreciable change.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-22 00:00:00.000", "description": "NECK SOFT TISSUES", "row_id": 1085807, "text": " 3:44 PM\n NECK SOFT TISSUES Clip # \n Reason: Food bolus in throat?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with recent FB bolus stuck in throat now w/ fever cough and\n sputum dark and foul smelling.\n REASON FOR THIS EXAMINATION:\n Food bolus in throat?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male with recent food bolus stuck in throat, presents\n with fever, cough and dark and foul-smelling sputum. Evaluate for food bolus\n in throat.\n\n AP AND LATERAL VIEWS OF THE NECK: There is no prior study available for\n comparison. No foreign body or radiopaque material is noted within the\n visualized portion of the trachea. The soft tissues of the neck and pre-\n vertebral region are unremarkable. Visualized osseous structures are\n unremarkable.\n\n IMPRESSION: No food bolus identified.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2190-09-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1254474, "text": " 7:41 AM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 68M with hypotension, pre-syncope\n REASON FOR THIS EXAMINATION:\n ? PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old man with hypertension, presyncope, question pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral views of the chest.\n\n FINDINGS: The lungs are clear. Cardiomediastinal silhouette and hilar\n contours are unremarkable. No effusion or pneumothorax. Aorta is tortuous.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "ECG", "chartdate": "2190-09-27 00:00:00.000", "description": "Report", "row_id": 299529, "text": "Sinus rhythm. Non-specific inferior ST-T wave changes similar to that recorded\non without diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2190-09-26 00:00:00.000", "description": "Report", "row_id": 299530, "text": "Sinus rhythm. Non-specific inferior ST-T wave changes. Compared to the\nprevious tracing of there is no significant difference.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-03-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 958083, "text": " 9:32 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: TACHYPNEA, TACHYCARDIA, HYPOXIA; EVAL FOR PE\n Admitting Diagnosis: WEAKNESS\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with tachypnea, tachycardia, hypoxia\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA chest with and without contrast with reconstructions.\n\n INDICATION: 83-year-old male with tachypnea, tachycardia and hypoxia, rule\n out PE.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n upper abdomen with IV contrast. Coronal, sagittal and oblique reconstructions\n were obtained.\n\n FINDINGS: Within the left lobe of the thyroid, there is a nodule measuring\n 2.8 cm x 1.8 cm and is heterogeneous in appearance. The major airways are\n patent down to the subsegmental level. No filling defects are identified\n within the pulmonary arteries to suggest pulmonary embolism. No paraaortic\n hematoma or evidence of dissection is identified. There is mediastinal\n lipomatosis. Multiple nodes are identified within the mediastinum, one of\n which measures 1.1 cm in smallest axis. No axillary lymphadenopathy\n identified.\n\n Centrilobular emphysema is identified. Centrilobular nodules identified with\n tree-in- pattern, most notable in the superior segment of the right lower\n lobe and within the posterior segment of the right upper lobe. Peribronchial\n wall thickening is identified.\n\n There is a 3.4 cm simple cyst within the upper pole of the right kidney. There\n is a hypodense ill-defined lesion within segment IV of the liver, not\n completely characterized on this study. A tubular structure of soft tissue\n density is identified in the region of the left adrenal gland which may be\n consistent with left adrenal hyperplasia. The right adrenal gland is more\n apparent and demonstrates prominent limbs.\n\n OSSEOUS STRUCTURES: Degenerative changes present in the thoracic spine with\n anterior osteophytosis. No compression deformities or suspicious lytic or\n sclerotic lesions identified.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism or aortic dissection.\n\n 2. Centrilobular opacities in the right lung most notable in the superior\n segment of the right lower lobe and posterior segment of the right upper lobe\n with underlying emphysema. Bilateral peribronchial wall thickening.\n (Over)\n\n 9:32 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: TACHYPNEA, TACHYCARDIA, HYPOXIA; EVAL FOR PE\n Admitting Diagnosis: WEAKNESS\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Differential diagnosis includes atypical mycobacterium infection versus\n bronchopneumonia.\n\n 3. Hypodense lesion within segment IV of the liver is incompletely\n characterized on this examination. Recommend multiphase liver MRI for further\n evaluation.\n\n 4. Tubular soft tissue density in the region of the left adrenal gland\n possibly representing adrenal hyperplasia.\n\n 5. Heterogeneous lesion within the left thyroid gland which may be further\n evaluated with ultrasound.\n\n 6. Scattered mediastinal and hilar lymph nodes, the largest of which measures\n 1.1 cm in short axis.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958061, "text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with tachycardia, decr. 02 sats\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST X-RAY\n\n INDICATION: 83-year-old male with tachycardia and decreased oxygen\n saturations. Assess for CHF.\n\n COMPARISONS: Film from at 12:43 p.m.\n\n FINDINGS: The heart size, mediastinal and hilar contours are within normal\n limits. There is tortuosity of the thoracic aorta. The pulmonary vasculature\n is normal. The lungs are clear. There are no pleural effusions, although the\n right costophrenic angle is incompletely seen.\n\n IMPRESSION: No evidence of CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-03-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 957998, "text": " 12:43 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pneumonia, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with malaise, chills, cough\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, CHF\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, .\n\n COMPARISON: .\n\n INDICATION: Malaise, chills and cough.\n\n The heart size, mediastinal and hilar contours are within normal limits and\n unchanged from the prior examination, with persistent mild tortuosity of the\n thoracic aorta. Pulmonary vascularity is normal. No definite areas of\n consolidation are identified within the lungs. Degenerative changes are\n present within the spine.\n\n IMPRESSION: No evidence of acute pneumonia. No pleural effusions or acute\n skeletal abnormalities are identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-03-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 958518, "text": " 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: PLEASE EVAL FOR INFILTRATE/EFFUSIONS\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with tachycardia, decr. 02 sats, CTA c/w pneumonia\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia, decreased saturation with pneumonia.\n\n COMPARISON: CTA chest and chest radiograph .\n\n Two views of the chest demonstrate a new ill-defined right retrocardiac\n opacity along with superimposed linear atelectasis. The cardiomediastinal\n contours and osseous structures are stable.\n\n IMPRESSION: Developing right lower lobe opacity, likely pneumonia. Follow-up\n recommended.\n\n" }, { "category": "ECG", "chartdate": "2185-03-29 00:00:00.000", "description": "Report", "row_id": 145133, "text": "Sinus rhythm\nRight branch block\nSince previous tracing of the same date, heart rate slower, axis less right\ninferior\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2185-03-30 00:00:00.000", "description": "Report", "row_id": 145129, "text": "Sinus rhythm. Right bundle-branch block. Occasional ventricular premature\nbeat. Compared to the previous tracing of ventricular ectopy has\nappeared.\n\n" }, { "category": "ECG", "chartdate": "2185-03-28 00:00:00.000", "description": "Report", "row_id": 145130, "text": "Technically difficult study\nSinus rhythm\nQRS 120 ms\n branch block\nEarly R wave progression\nVertical axis (90)\nS1, S2, S3 pattern\nConsider right ventricular hypertrophy, pulmonary disease, left posterior\nhemiblock, pulmonary embolism\nSince previous tracing, axis, and right branch block new\n\n" }, { "category": "ECG", "chartdate": "2185-03-28 00:00:00.000", "description": "Report", "row_id": 145131, "text": "Sinus tachycardia\nAbnormal extreme QRS axis deviation\nRight branch block\nConsider old inferior infarct, Left posterior hemiblock\nSince previous tracing of the same date, heart rate faster, axis more right\ninferior\n\n" }, { "category": "ECG", "chartdate": "2185-03-29 00:00:00.000", "description": "Report", "row_id": 145132, "text": "Sinus tachycardia\nFrequent premature ventricular contractions\nPossible inferior infarct - age undetermined, left posterior hemiblock\n(axis right inferior)\nSince previous tracing of , ventricular premature complex new\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-29 00:00:00.000", "description": "Report", "row_id": 1531767, "text": "83 YEAR OLD GENTLEMAN ARRIVED AT THE EW AFTER \"NOT FEELING WELL AT HOME FOR A FEW DAYS\". PT LIVES IN AN FACILITY. UPON ARRIVAL TO THE EW PT WAS AFEBRILE WITH STABLE VS WITH LACTATE OF 2.5 AND WBC'S OF 12. AFTER SEVERAL HOURS PT BECAME FEBRILE AT 100.5 WITH CHILLS AND TACHYCARDIC TO THE 140'S. CTA WAS DONE AND PE WAS RULED OUT. PT CAME TO MICU FOR FURTHER MANAGEMENT OF PNA.\n\nCV: B/P HAS RANGED FROM 128/65 AT REST TO 178/88 WHEN ANXIOUS. NSR/ST WITH HR RANGING FROM 73, AFTER LOPRESSOR DOSE OF 100MG PO TO 129 PRIOR TO LOPRESSOR AND PT WAS ANXIOUS. PT DID A BOLUS OF 500CC TO BRING HR DOWN WITH NO NOTICABLE EFFECT. PPP BILAT. AT 0100 K+ WAS 3.6 PT 40MEQ OF KCL. MG+ 1.8, PT MAG 2GM IV. PT HAS HAD FREQUENT PVC'S WHICH HAVE DECREASED SINCE LYTES HAVE BEEN REPLENISHED.\n\nRESP: UPON ARRIVAL LUNGS WERE DIM WITH FINE EXP WHEEZES, PT WAS ALSO ANXIOUS AT THIS TIME. AFTER PT RESTED LUNGS REMAINED CLEAR AND DIM. SAO2 DID REMAIN IN THE 90'S WITH N/C 3L. RR 18-34. PT IS COUGHING UP VERY THICK YELLOW SPUTUM, SPEC SENT FOR CULTURE.\n\nNEURO: A&OX3. HAS DENIED PAIN. PT DOES BECOME VERY ANXIOUS AND ASKS QUESTIONS FREQUENTLY ABOUT MEDS AND TREATMENTS. DID LORAZEPAM 0.5MG IV FOR ANXIETY WITH SOME HELP.\n\nGU: FOLEY CATH WAS INSERTED WITHOUT DIFFICULTY. PT HAD BEEN WEARING A DISPOSABLE PAD WHICH WAS SATURATED. FOLEY DRAINING DARK YELLOW URINE IN ADEQUATE AMTS.\n\nGI: ABD SOFT AND NON TENDER. BS+. DRINKING PO FLUIDS, TOL WELL.\n\nENDO: ON SSIC WITH HUMALOG INSULIN.\n\nSKIN: PT HAS APPROX 5CM AREA ON L ANTERIOR ANKLE WHICH IS REDDENED AND SCALEY DRY.\n\nPLAN: CONT TO MONITOR RESP STATUS AND PROVIDE RESP SUPPORT AS NEEDED. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED. CONT WITH ATB. SISTER IN LAW IS HCP, UPDATE WITH ANY CHANGES IN PT CONDITION.\n" } ]

[ { "category": "Echo", "chartdate": "2165-11-04 00:00:00.000", "description": "Report", "row_id": 77163, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 126\nBSA (m2): 1.59 m2\nBP (mm Hg): 92/56\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 13:47\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 size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thicknesses and cavity size. Moderate regional LV\nsystolic dysfunction. No LV mass/thrombus. False LV tendon (normal variant).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex-\nakinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. 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. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: Small 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.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction. No masses or thrombi are seen in the left ventricle. Resting\nregional wall motion abnormalities include near akinesis of the distal halves\nof the septum and anterior wall. The distal inferior and apical segments are\nalso akinetic. No left ventricular thrombus or discrete aneurysm is seen.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is a small anterior pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD\nlesion). Mild mitral regurgitation. Small anterior pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , the left\nventricular wall motion abnormalites are more clearly defined. The severity of\nmitral regurgitation is decreased.\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": "Echo", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 78543, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Syncope.\nHeight: (in) 63\nWeight (lb): 126\nBSA (m2): 1.59 m2\nBP (mm Hg): 89/54\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 08:05\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\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: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nViews of left ventricular function were limited. There appeared to be at least\nmild regional left ventricular systolic dysfunction with hypokinesis of the\nlateral apex. Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\nmitral regurgitation is seen. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843570, "text": " 5:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with cp, large ST elevation MI\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 year old with chest pain and ST elevations.\n\n Portable upright frontal radiograph. No prior studies.\n\n FINDINGS:\n\n Cardiac and mediastinal contours are normal. The lungs are clear. Pulmonary\n vasculature is normal. There is no pneumothorax. The osseous structures are\n grossly unremarkable.\n\n IMPRESSION:\n\n No CHF.\n\n" }, { "category": "Radiology", "chartdate": "2165-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843593, "text": " 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess IABP placement\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with cp, large ST elevation MI s/p PCI and IABP placement in\n cath lab.\n REASON FOR THIS EXAMINATION:\n please assess IABP placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain, status post BCI and IABP placement.\n\n CHEST, SINGLE AP PORTABLE SUPINE VIEW:\n\n The heart is not enlarged for technique. A femoral approach IABP is present,\n with radiopaque tip lying along the inferior edge of the aortic knob. Two\n very small radiopaque markers are superimposed over the spine, one to the left\n of the T6 vertebral body and one overlying the L3-4 disc space. These are of\n unknown etiology or significance to me, but are new compared with film from\n earlier the same day. Also new compared with earlier the same day is a faint\n alveolar opacity superimposed over both lungs. This most likely represents\n dependent atelectasis, given its rapid evolution and absence of upper zone\n redistribution or effusions. However, attention to this finding on follow-up\n films is recommended to exclude a superimposed pulmonary process.\n\n" }, { "category": "ECG", "chartdate": "2165-11-06 00:00:00.000", "description": "Report", "row_id": 183790, "text": "Sinus rhythm. Anterior (and question lateral) myocardial infarction with\nST-T wave configuration suggesting acute/recent/in evolution process.\nST segment elevation is diffuse - consider also pericarditis. Borderline\nlow QRS voltage. Clinical correlation is suggested. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2165-11-04 00:00:00.000", "description": "Report", "row_id": 183791, "text": "Sinus rhythm. Baseline artifact. Anterior (and question lateral) myocardial\ninfarction with ST-T wave configuration sugggesting acute/recent/in evolution\nprocess. ST segment elevation is diffuse. Consider also pericarditis.\nBorderline low QRS voltage. Clinical correlation is suggested. Since the\nprevious tracing earlier this date precordial QRS voltage is less prominent.\n\n" }, { "category": "ECG", "chartdate": "2165-11-04 00:00:00.000", "description": "Report", "row_id": 183792, "text": "Sinus rhythm\nPossible acute anterior infarct\nInferior and lateral ST elevation, consider recent infarction\nLow QRS voltages in precordial leads\nSince previous tracing of , inferior/anterior ST segment elevation has\nreappeared.\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 183793, "text": "Sinus rhythm\nPossible old anterior infarct\nLow QRS voltages in limb leads\nLeft atrial abnormality\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 183794, "text": "Sinus rhythm\nPossible old anterior infarct\nLow QRS voltages in limb leads\nLeft atrial abnormality\nSince previous tracing of , anterior/inferior ST segment elevations\nresolved\n\n" }, { "category": "ECG", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 183795, "text": "Sinus rhythm\nST segment elevation in V2-V5 consistent with acute anterior wall myocardial\ninfarction\nCompared to previous tracing, ST segment elevation more widespread\n\n" }, { "category": "ECG", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 183796, "text": "Sinus rhythm\nProbable old inferior infarct\nQRS changes V3/V4 - probably due to LVH but consider anterior infarct\nHyperacute T waves in leads V4,V5 consider acute anterior current of\ninjury/myocardial infarction\n\n" }, { "category": "Nursing/other", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 1443249, "text": "ARRIVED IN CSRU @ 0945. IABP 1:1 W/ FAIR AUGUMENTATION. RIGHT IABP SITE OOZY. DSG CHANGED. + PAL PEDAL PULSES BILAT. HEPARIN INFUSING @ 700 U/HR. INTEGLARIN INFUSING @ 2 UCG/KG/MIN. GIVEN FENTANYL 25 UCG FOR C/O CHEST PAIN. PL~. EPISODE OF N/V. ZOFRAN GIVEN EFFECTIVE. CATH SITE CONT TO OOZE. CCU TEAM NOTIFIED. FOUND TO BE BLEEDING FROM INSERTION SITE. PTT~136. HEP STOPPED. REPEAT PTT~150. DETERMINED THAT BALLOON PUMP NEEDED TO BE DC'D. WEANED~1:4. SUCCESSFULLY. TO BE WHEN PTT LEVELS ARE WNL (<50). CI>2 VIA FICK.\nMORPHINE FOR PAIN. INEFFECTIVE. GIVEN ANOTHER DOSE OF FENTANYL 25 UCG'S. ZOFRAN AGAIN FOR NAUSEA. RESTING COMFORTABLY. ELECTROLYTES REPLETED. NEURO~INTACT. RESP~WNL. DIURESING WELL. PT HAVING MENSES. COUSIN IN VISITING.\n" }, { "category": "Nursing/other", "chartdate": "2165-11-03 00:00:00.000", "description": "Report", "row_id": 1443250, "text": "Pt. had IABP d'cd at 2145 by Dr. ; she had sudden vagal reaction with drop in SBP to 60 associated with nausea and vomiting. Pt. stated that she felt dizzy (hob was flat). Atropine .5 mg ivp given by Dr. , NS open wide for total of 600cc. Zofran 2mg ivp x2 given. Dopamine started and titrated up to 10mcq/kg/min until SBP >100. Weaned back to off with SBP kept >100. Right fem/ pressure maintained by Dr. ; swan d'cd once hemostasis of IABP site stable. Both sites flat without bleeding. Peripheral pedal pulse palpable. Pt. warmed with blankets after feeling cold. Fell asleep.\nNBP @q15 min intervals. NS to for 3 hours M.D. Dr. made aware of events (ccu team) and present to see pt. with Dr. . Will observe and keep vss at q 15 min for first hour.\n" }, { "category": "Nursing/other", "chartdate": "2165-11-04 00:00:00.000", "description": "Report", "row_id": 1443251, "text": "Pt. slept most of the night after vagal episode. All chest pain is gone. HCT @ 2400 = 26. Recieved one prbc after over 3 hours; transfusion consent obtained by Dr. . Right fem site is without bleeding or hematoma. Pedal pulse palpable. Integrillin was stopped at 0100. No further n/v. Voiding QS per foley. Pt. within her menstrual cycle.\n" }, { "category": "Nursing/other", "chartdate": "2165-11-04 00:00:00.000", "description": "Report", "row_id": 1443252, "text": "PT UPDATE\n PT IS S/P STENTS X2 ON .\n\n NEURO: PT IS A&O X3. VERY QUIET. DIFFICULT TO ASSESS HOW PT IS HANDLING THE EVENTS THAT HAVE TAKEN PLACE RATHER QUICKLY THE LAST FEW DAYS.\n\n RESP: BS CLEAR. SATS 100 ON 3LNP.\n\n CV: HR THIS AM LOW 100'S. BECAME INCREASINGLY TACHYCARDIC-UP TO 110. TEAM CALLED-STATED THEY WERE COMING DOWN TO DO ROUNDS. HR UP TO 120 BY THE TIME TEAM CAME DOWN. SBP 90-95/60'S. CARDIAC ECHO DONE THIS AFTERNOON-DR. BY TO SEE RESULTS OF ECHO. TEAM HAD DISCUSSED STARTING ESMOLOL; NO ORDER YET AND RESIDENT DOWN -PT GIVEN DOSE OF LOPRESSOR AT 1330 (DUE AT 1500). HR DOWN TO 110 RANGE BEFORE LOPRESSOR. PT DENIES ANY PAIN AT ALL. CK DOWN TO 1263 FROM . EKG DONE THIS AM-REVIEWED BY TEAM-?ST ELEV. REPEATED 1130 AND REVIEWED BY TEAM AND DR. . RT GROIN SITE C&D.\n\n GU: CONT WITH GOOD U/O.\n\n GI: PT HAD JUICE THIS AM-NOW NPO UNTIL PLAN DETERMINED.\n\n LAB: REPEAT HCT 27.9 AFTER RECEIVING 1 PC-TO RECEIVE ANOTHER PC.\n\n A/P: PT LOOKS AND FEELS MUCH BETTER. REMAINS PAIN FREE. GIVE ANOTHER PC WHEN READY. PLAN IS TO KEEP PT IN ICU TO CONT TO WATCH CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2165-11-05 00:00:00.000", "description": "Report", "row_id": 1443253, "text": "returned from cath lab at ~ .left groin site dry and intact with a tegaderm dressing,no bleeding.sbp 90's/ hr 106 st no ectopy.remained flat for the next three hours.no bleeding pedal pulses easily palp and pt tibial palp.\n\nresp: o2 at 3 l nc o2 sats 99-100 %. breath sounds clear bilateral upper and lower.\n\ngi: positive bowel sounds.abdomen soft. no nausea no vomiting. tolerated liquids.\n\ngu: foley draining clear yellow urine initially...now draining amber with sediment..ua and c&s sent after ? tx reaction vs other origin.\n\nneuro: alert and oriented, calm and cooperative.\n\nfebrile episode: pt received 1 unit prbc;s for hct of 28 post cath. unit went up at 2400 and finished at 0140. at ~ 0130 pt complained of shaking chills..temp 99.7 and within 5 minutes up to 100,6 po. ho notified. pt given 650 mg tylenol and dr to see patient. 1 hour after tranfusion completed pt with temp to 102.2..hr 108-112 and bp low 90's dr and over to see patient. tranfusion reaction workup begun and blood cultures times 2 peripheral adn stat lab work drawn., hct after this 3 rd unit up to 31. pt also c/o low back pain ho aware. no signs of bleeding at either groin site. no swelling so ecchymosis.bp dropped to 80/ this a.m. with tachy to 108 so fluid bolus 250 ccns times 2 with good responsehr down to 94 and bp 87/58 after bolus.sbp continues to drop into 80's when pt asleep.\n\nPlan: await results of tranfusion reaction work up. check blood cultures and urine culture and ua.monitir for s&s of bleeding check groins sites\n" }, { "category": "Nursing/other", "chartdate": "2165-11-05 00:00:00.000", "description": "Report", "row_id": 1443254, "text": "NEURO ALERT ORIENTED X3 MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nRESP NC 2L SATS 100% LUNGS CLEAR DIMINISHED R SIDE\n\nC/V NSR ST NO ECT B/P 80-90 SYTOLIC PATIENT STATES BASELINE B/P 90S SYSTOLIC PALP PULSES NO CP\n\nGU/GI ABD SOFT BOWEL SOUNDS HEARD FOLEY DC/D 11AM AMBER URINE DTV 5-7PM TOL DIET WELL\n\nPLAN TRANSFER TO 6 TODAY CONTINUE TO EVAL SYMPTOMS OF POSSIBLE TX REACTION FROM OVERNOC\n" }, { "category": "Nursing/other", "chartdate": "2165-11-06 00:00:00.000", "description": "Report", "row_id": 1443255, "text": "Pt. slept most of the night other than to get oob to commode and for blood drawings. Pt. stated that she felt a sharp pain in her chest that went away as soon as it came on: may have been associated with getting up to commode. She has maintained BP in the 80's throughout. Lopressor held. Old IV's pulled and #20 saline lock placed in right wrist. Pt. is prepared to be transferred to f3.\n" } ]

[ { "category": "Radiology", "chartdate": "2133-08-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 969610, "text": " 3:50 PM\n CHEST (PA & LAT) Clip # \n Reason: pre-op\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with pre op for valve\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man preop for valve replacement.\n\n COMPARISON: None.\n\n FRONTAL AND LATERAL CHEST: The heart size does not appear enlarged. There is\n mild calcification of the aortic knob. The hila appear unremarkable.\n Pulmonary vascularity appears normal. The lungs are clear. No pleural\n effusions are seen. Osseous structures demonstrate osteopenia and\n degenerative changes.\n\n IMPRESSION: No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970324, "text": " 12:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o inf, eff, acutely SOB\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR, new confusion\n\n REASON FOR THIS EXAMINATION:\n r/o inf, eff, acutely SOB\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Acute shortness of breath in the patient after recent\n mitral valve replacement.\n\n Portable AP chest radiograph compared to .\n\n The heart size has slightly increased compared to recent radiographs obtained\n at 11:00 a.m., the same day.\n\n The lung volumes are low. This may partially cause increased vascular\n margins, although pulmonary edema cannot be excluded. Small bilateral pleural\n effusion most likely present.\n\n The right internal jugular line chest is in unchanged position.\n\n IMPRESSION: Slightly increased heart size during short-term interval.\n Pericardial effusion should be excluded. Possible interstitial pulmonary\n edema.\n\n The findings were discussed with on , 3:30pm.\n\n" }, { "category": "Radiology", "chartdate": "2133-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970248, "text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR, new confusion\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient after mitral valve replacement.\n\n Portable AP chest radiograph compared to , obtained at 2:42 p.m.\n\n The heart size is moderately enlarged but stable. The replaced mitral valve\n is again noted in unchanged position. The sternal sutures are intact.\n\n The right internal jugular vein sheath is again noted.\n\n Minimal perihilar increased interstitial markings are grossly unchanged with\n no evidence of congestive heart failure. Small bilateral pleural effusion\n cannot be excluded.\n\n There is no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-08-23 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 969697, "text": " 12:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: preop for MVR; need to assess aortic calcifications\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with aortic calcifications\n REASON FOR THIS EXAMINATION:\n preop for MVR; need to assess aortic calcifications\n CONTRAINDICATIONS for IV CONTRAST:\n preop for MVR; need to assess aortic calcifications\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op for mitral valve repair, assess aortic calcifications.\n\n COMPARISON: PA and lateral views of the chest .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to\n the upper abdomen were obtained without intravenous contrast. Coronal\n reconstructions were performed.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: No pathologically enlarged\n mediastinal, hilar, or axillary lymph nodes are present. Calcified right\n hilar lymph nodes are identified consistent with prior granulomatous disease.\n The thoracic aorta is normal in caliber. The descending thoracic aorta is\n free of mural calcifications. Diffuse atherosclerotic calcification is seen\n involving the aortic arch and descending aorta, including at the takeoff of\n the great vessels. Mild calcifications are seen involving the left main and\n left anterior descending coronary artery. Heart and pericardium otherwise are\n unremarkable. No pleural or pericardial effusions are present.\n\n Lung window images are somewhat limited secondary to respiratory motion.\n Centrilobular emphysema is most pronounced involving the upper lobes.\n Additionally, peripheral inter- and intra-lobular septal thickening is present\n involving both lungs with a focal area of peripheral bronchiolectasis\n involving the posterior segment of the right upper lobe. Several calcified\n granulomas are seen throughout both lungs. No areas of focal consolidation\n are noted. Airways are patent to the level of segmental bronchi bilaterally.\n\n Small hiatal hernia is present. Tiny calcified foci are seen within the\n spleen consistent with prior granulomatous disease. Imaged portion of the\n liver, pancreas, kidneys, adrenal glands, gallbladder, and bowel loops appear\n unremarkable.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n demonstrated. Mild degenerative changes are seen in the thoracic spine.\n\n IMPRESSION:\n 1. Diffuse atherosclerotic mural calcifications involving the aortic arch and\n descending aorta. The ascending aorta is free of mural calcifications.\n 2. Calcified hilar lymph nodes and granulomas within the lungs and spleen are\n consistent with prior granulomatous infection.\n 3. Moderate centrilobular emphysema.\n (Over)\n\n 12:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: preop for MVR; need to assess aortic calcifications\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Diffuse interstitial lung disease, with features suggestive of pulmonary\n fibrosis. Further evaluation with high- resolution CT of the chest is\n recommended if clinically indicated.\n 5. Small hiatal hernia.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2133-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970309, "text": " 11:07 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR, new confusion\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: MVR with new confusion.\n\n There has been no change since the previous film of the same date. The cordis\n catheter is in the proximal SVC. Status post median sternotomy. No\n pneumothorax. There is slight cardiomegaly and tortuosity of the thoracic\n aorta but no definite pulmonary edema or pulmonary consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-08-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969854, "text": " 1:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film- contact NP # if abnormal\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n postop film- contact NP # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Mitral valve replacement.\n\n Single AP view of the chest is obtained on at 14:17 hours following\n the thoracic surgery for mitral valve replacement. Patient remains intubated\n with the tip of the ET tube approximately 4.5 cm above the carina. A Swan-\n Ganz catheter is in place with its tip directed towards the right main\n pulmonary artery. Mediastinal drains are present. There is increased\n retrocardiac density on the left side consistent with air space\n disease/atelectasis in the left lower lobe with likely a small left pleural\n effusion. There is no evidence of large pneumothorax.\n\n IMPRESSION:\n\n Status post mitral valve replacement with expected postoperative drain and\n line placements. Likely left lower lobe atelectasis with small left pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2133-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970189, "text": " 2:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of MVR.\n\n Status post median sternotomy/MVR. The Cordis catheter has tip overlying the\n junction of the right brachiocephalic vein and SVC. Chest tube is present in\n the left lower hemithorax. Mediastinal and nasogastric tubes noted previously\n have been removed. No pneumothorax. Minimal residual atelectasis at left\n lung base. Calcified focus consistent with calcified granuloma in left upper\n zone as previously demonstrated. No change in heart size or mediastinal width\n since the previous film.\n\n" }, { "category": "Radiology", "chartdate": "2133-09-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 971680, "text": " 9:51 AM\n CHEST (PA & LAT) Clip # \n Reason: Pleural effusion\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p MVR\n\n REASON FOR THIS EXAMINATION:\n Pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n HISTORY: MVR.\n\n Two views. Comparison with .\n\n There is continued evidence of mild pulmonary vascular congestion and small\n pleural effusions. A calcified granuloma is again demonstrated on the left.\n The patient is status post median sternotomy and MVR. Mediastinal structures\n are unchanged. A right internal jugular catheter has been removed. There is\n no other significant interval change.\n\n IMPRESSION: No significant change post removal of right internal jugular\n catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-09-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 970952, "text": " 1:22 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf., eff\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p MVR\n REASON FOR THIS EXAMINATION:\n r/o inf., eff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVR, query infiltrate or effusion.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: A right internal jugular catheter is again seen with its\n tip in the lower SVC. Non-disrupted median sternotomy wires are again seen.\n Cardiac size is moderately enlarged and mediastinal and hilar contours are\n normal and unchanged. Vascular congestion is essentially unchanged. There is\n a new small left pleural effusion. No pneumothorax. No focal destructive\n lytic osseous lesion.\n\n IMPRESSION: New small left pleural effusion and otherwise essentially\n unchanged radiographic chest showing mild vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2133-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970476, "text": " 1:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR, new confusion/wheezing\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Wheezing in patient after mitral valve replacement.\n\n Portable AP chest radiograph compared to .\n\n The lung volumes have improved on the current radiograph compared to the\n previous study. The cardiomediastinal silhouette is stable. The replaced\n mitral valve is in expected position. There is no sizable change in degree of\n mild-to-moderate pulmonary edema. No sizeable pleural effusion or\n pneumothorax is identified. The right internal jugular line catheter tip\n terminates in upper SVC.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-09-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 971256, "text": " 9:30 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p MVR\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n\n TWO VIEWS OF THE CHEST ON \n\n No change since an exam on . The heart is enlarged. A right jugular line\n is in place with the tip in the superior vena cava near the right atrium.\n Sternal sutures noted. There is still a small amount of atelectasis and some\n vascular congestion especially at the left base and a small left effusion.\n Incidental note is made of a prominent calcified granuloma lying just over the\n left posterior sixth rib. This was described in the previous CT report.\n\n CONCLUSION: Perhaps minor improvement but overall still some atelectasis and\n effusion and vascular congestion present.\n\n" }, { "category": "Radiology", "chartdate": "2133-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970492, "text": " 3:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o ptx, check line placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p MVR, new confusion/wheezing\n\n REASON FOR THIS EXAMINATION:\n r/o ptx, check line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Previous study earlier the same date.\n\n INDICATION: Line placement.\n\n Right internal jugular vascular sheath has been removed and replaced by a\n right internal jugular vascular catheter, terminating in the proximal to mid\n superior vena cava. There is no pneumothorax, and otherwise no change from\n the recent radiograph of approximately two hours earlier.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-24 00:00:00.000", "description": "Report", "row_id": 1656375, "text": "appears hypovolemic with low filling pressures,labile bp,brisk huo & ongoing metabolic acidosis with acceptable svo2 & cardiac output.volume given,a paced(underlying juctional) at a higher rate allowing neo to be weaned,labs pending.awoke on low dose propofol initially appeared somewhat spastic & jerky. propofol increased & paralytics reversed.awoke again despite increased propofol agitated,thrashing,not following commands but moving all extremities.opening eyes to voice.morphine given for presumed pain. svo2 into the 40's with hypotension,elevated pap's & loss of atrial sensing/capture.underlying rhythm now junctional 50's,polarity changed,sensitivity adjusted with intermittent capture only. n.p. to bedside,av paced with improved capture(although occasionally misses) & epi increased with improvement. plan to start precedex for weaning.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-24 00:00:00.000", "description": "Report", "row_id": 1656376, "text": "failed waking & weaning attempt despite high dose precedex & intermittent dose of midazolam evinced by agitation,restlessness,thrashing with pas into the 60's,svo2 into the 30's with hypotension.reseated again with propofol & morphine given for what appeared to be back pain. (twisting in bed,raising torso off mattrress & nodding yes to pain)with improved bp & svo2. remains av paced on epi for chronotropy.wife updated via phone,see flow sheet.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-24 00:00:00.000", "description": "Report", "row_id": 1656377, "text": "radial & femoral a line scoorelate after transduced individually.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-25 00:00:00.000", "description": "Report", "row_id": 1656378, "text": "Neuro: Pt received sedated on propofol @ 45 mck/kg/min, able to weaned down to 30 mcg/kg/min to keep pt comfortable but lightly sedated; weak cough when suctioning, attempted to open eyes when told to do so\n\nCV: Afebrile; AV paced @ 84, underlying junctiona; @ 30's, 2A 2V wires, both sensing & capturing, A wires' mA turned down to 8; SBP 90's-100's, neo infusing @ 1 mcg/kg/min; epi running @ 0.02 mcg/kg/min @ beginning of shift, weaned to 0.01 mcg/kg/min, CO remained >4; palpable pulses x4; R fem a line correlate with R rad a line when pressure is higher, PAD 20's, CVP low teens, CI >2; hypotensive to 70's & SvO2 decreased to 40's with turn & activity when awake, need to resedate pt to settle\n\nResp: Lung sound clear @ bases, exp wheeze @ upper lobes; intubated ,SIMV 60% FiO2, 5 PEEP & 5 PS RR 16, PaO2 80's-90's, PEEP increased to 7 in attempt to wean FiO2; CT to suction with serrousang drainage, -leak, -crepitus\n\nGI: Abd soft distended, hypo bowel sound; NGT to LCS, bilious drainage, placement check with air bolus auscultation\n\nGU: Foley draining clear yellow urine, UO >100 ml/hr\n\nInteg: Intact\n\nEndo: Cover per CSRU protocol\n\nID: on post-op vanco dose\n\nPlan: monitor hemodynamics, resp status & labs; wake & wean to extubate; ?reattempt precedex; check return of rhythm\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-25 00:00:00.000", "description": "Report", "row_id": 1656379, "text": "Resp care note\n\nPt is weaned to PSV 5/=5. RSBI 30, pt req minimal sx. Bs are clear. last ABG , Po2 96 on 7 Peep.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-29 00:00:00.000", "description": "Report", "row_id": 1656392, "text": " 7a-7p\nneuro: very lethargic this am, difficult to rouse. pt kept npo this am r/t lethargy and inability to protect own airway. perrlaa. towards this pm pt more alert, oriented x2-3, follows commands. restraints removed this pm with pt's family visiting, pt currently calm alone and not requiring restraint\n\ncv: a paced this am, found to be sb under pacer, pacer set to aai 50, pt sb 55-75 no ectopy. sbp 100-130. afeb.\n\nresp: lungs cta when sleeping, very wheezy when awake. will return to cta when pt calms down. strong nonproductive cough. neb treatments q4h. weaned face tent to 35%, nc to off. pt 02 sat 94-98% on face tent fi02 35%.\n\ngi: hypoactive bowel sounds, soft distended belly. small-moderate medium brown fecal smear (no blood apparent). no insulin needs today.\n\ngu: foley to gravity draining clear yellow urine, good reaction to 80mg iv lasix tid, currently -2L for past 24h\n\nlabs: repleted k+ and ca++\n\nassess: improving respiratory and neurological status\n\nplan: pulmonary toilet, increase activity, reorient as needed, hold haldol?, iv lasix to ?\n" }, { "category": "Nursing/other", "chartdate": "2133-08-30 00:00:00.000", "description": "Report", "row_id": 1656393, "text": "neuro- slept first half of noc then awoke and sta\u0013yed awake most of the noc. dosed off after medicated with haldol IM. appropriate actions,oriented to self and cooperative and understanding of care.answered questions correctly.mae freely.no attempts to get oob or pull at invasive lines.ultram 50mg po x1 with moderate effect.\n\n\ncv- nsr rate 80-90. bp stable. pacer attached but shut off.\n\nresp-regular resp rate with clear lung sounds when asleep. instanly becomes tachypneic with audible wheezes and rt sided crackles when awake.nebs q4h with increase need for fi02 to 80% for desaturation.lasix decreased to . diureses well.\n\ngi- abd soft. + bs. small soft stool (on pad) after coughing. ate a small amt ice cream without difficulty.\n\ngu- adequate hourly u/o with moderate increase in diureses after lasix iv.\n\nlabs- pending\n\npain- pt saying \"oh this hurts\" when turned side to side for line change. resting comfortable afterwards.\n\nplan- continue with pulm. hygeine. monitor i/o. increase diet & activity as tol.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-30 00:00:00.000", "description": "Report", "row_id": 1656394, "text": " 7a-7p\nneuro: a+o x3, mae, follows commands, attempted to transfer to chair, but with dangling at bedside heart rate increased to 130s and 02 sats dropped to 80s pt became moderately wheezy, pt returned to bed\n\ncv: sr 90s this am-> afib 100-130, lopressor 2.5mg iv x2 dropped heart rate to 80-90 for short term, then returned to 100-130; amio gtt started and rate controlled to 80-100, but returned to 100-130 with attempted transfer to chair; afeb; sbp 100-130\n\nresp: lungs cta, diminished to bases, 02 sats 80-99%, now >96% on fi02 70% face tent with 6L nc, is to 750ml, strong nonproductive cough, becomes wheezy with exertion; nebs q4h\n\ngi: tolerating small amounts regular diet, 4 units regular insulin sc this pm, small fecal smear this pm (pt unaware of stooling)\n\ngu: foley to gravity, brisk diuresis following pm lasix dose (given early for low uop)\n\nlabs: repleted k+/ca++\n\nassess: stable\n\nplan: pulmonary toilet, continue diuresis, increase activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2133-08-28 00:00:00.000", "description": "Report", "row_id": 1656387, "text": "RESP CARE NOTE\nPT ORDERED FOR COMBIVENT MDI Q4, FLOVENT , AND ALBUTERO SVN PRN. PT IS CONFUSED AND UNABLE TO MDI. RECOMMENDED TO CHANGE OVER TO ALB/ATR SVN Q4 FOR NOW. BREATH SOUNDS WITH BILATERAL EXP WHEEZES AND AUDIBLE WITH ANY EXERTION. ONLY CHANGE POST SVN IS INCREASED AUDIBLE WHEEZES. MAINTAINING SATS WITH NASAL CANNULA. PT RESTRAINED AND REQUIRES A ONE TO ONE. SVN HELD WHEN PT IS SLEEPING.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-28 00:00:00.000", "description": "Report", "row_id": 1656388, "text": "neuro-completely agitated,restless, calling out and constantly moving legs and attempting to sit up in bed when not medicated with ivp ativan.after medicated he quickly falls asleep and stays asleep until stimulated. not oriented at anytime.\n\ncv- afib rate=115-125 po amiodarione.htn/tachypneic when agitated and restless.heparin gtt700u/hr with ptt=34.3 inr=1.3. skin w-d-i, palp pulses.\n\nresp- audible exp wheeze,excaberated with tachypnea. albuterol nebs prn. with no change in breath sounds or breathing pattern. strong non-productive cough. 3lnc=98%.\n\ngi- abd softly distended. + bs. no bm. fluid restriction 100ml/24h d/t hyponatremia.\n\ngu-diuresing with scheduled lasix TID, then drifts downward. took po medication with sips of h20.\n\nlabs-k+ repleted x1.\n\nplan- continue to monitor and tx s/sx of ETOH withdrawals. nebs/inh a/o. cpt. pulm hygeine. check ptt/pt level fo heparin gtt.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-28 00:00:00.000", "description": "Report", "row_id": 1656389, "text": "NPN: Review of Systems\nNeuro: Pt increasingly agitated: pulling oxygen off, leaning forward, and grasping at tubes. Confused; able to tell me his name, sometimes the year, and said he was in the . Breathing during these periods labored, audible wheezes, HR up to 130s. Medicated w/ haldol and ativan until sedated for Pt's safety. Last dose of ativan was 2mg, in 1mg increments, at 1430. Currently sleeping. Will rouse w/ stimulation, and follows intermittently. Pt has consistantly denied pain.\n\nResp: As noted above, audible expiratory wheezing bilaterally. Slight improvement after nebulizers, but worsens again w/ activity. Sao2 down to 88% on 6L NC. Currently on 70% cool neb w/ Sao2=97%. RR at rest=teens and up to 40s when agitated. NP , CXR revealed lungs slightly wet. Lasix dose increased to 80mg TID.\n\nCV: Atrial fibrillation w/ HR up to 130s-> Amiodarone bolus and drip of 1mg/min started. HR now 80s-90s. No ectopy. MAP 60s. K+ repleted as ordered. Afebrile. Palpable DP/PT pulses bilaterally. Pacing wires secured to chest. RIJ trauma line changed to triple lumen over a wire. Chest dressing dry and intact.\n\nGI/heme: Abdomen is distended/soft. Took 10am medications orally w/ water, no difficulty observed. No c/o nausea. (+) bowel sounds. Moderate amt of red clots per rectum-> heparin stopped. INR=1.2. HCT=28.5 from 26.7. No further bleeding observed. HCT rechecked at 1600 and =25.4. NP notified-> plan to recheck at 2100. FS glucose=145, 4 units of regular insulin per sliding scale.\n\nSkin: Pink rash on back. No pressure wounds present. Skin pale. Echymotic areas on abdomen and back.\n\nSocial: Wife and sons in to visit. Aware of Pt's agitation and need for sedation. Per\n\nA: Tenuous resp. status when agitated. HR improved after amiodarone started. HCT drop from previous level. Heparin remains off.\n\nP: Sedate as needed to maintain comfort/ safety. Diurese as ordered. Nebulizeres.Recheck HCT 2100. ? Cardiovert per EP.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-28 00:00:00.000", "description": "Report", "row_id": 1656390, "text": "NPN: Addendum\nPt becoming increasingly agitated. Breathing labored. 1mg ativan given. Audible wheezing. Neb treatment given. No improvement in wheezing. Fio2 increased to 100% on cool neb d/t decrease in SAo2 to 88%. Pt still restless-> additional 1mg ativan given. Pt calmer. Wheezing improved. Respiratory pattern still labored, but rate 17-19. 150mg amiodarone bolus given. Anticipate cardioversion d/t heparin off and Pt in rate controlled atrial fibrillation. Awaiting arrival of anesthesia. Possible intubation for airway protection.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-29 00:00:00.000", "description": "Report", "row_id": 1656391, "text": " PT SPONTANEOUSLY AWAKENS HE BECOMES RESTLESS,AGITATED,MOVING LEGS ALL OVER BED & ATTEMPTING TO LIFT UPPER BODY OFF BED. MOANS/GROANS WITH UNCOMPREHENSIBLE WORDS. WILL ANSWER TO HIS NAME.DOES NOT FOLLOW ANY COMMANDS,BUT IS EASILY TALKED DOWN FROM ESCALATING AGITATION LEVELS.ATIVAN PRN (LESS EFFECTIVE) THAN HALDOL IM.\n\nCV- AFIB,RATE CONTROLLED. AMIO GTT @ 1.0MG/MIN. HEPARIN GTT DCD EARLIER IN DAY. BP STABLE. ELECTIVELY CARDIOVERTED WITH 200 JOULES X1. PT WITH SUCCICHOLINE AND ANESTHESIA PRESENT AT TIME OF CARDIOVERSION.PT CARDIOVERTED INTO SLOW JUNC VS. AV DISSASOCIATION VS. CHB INTERMITTENTLY.AMIO GTT SHUT OFF.JUNCTIONAL BRADYCARDIA RATE 48-52. A-PACED @ 60 VIA EPICARDIAL WIRES.\n\n AWAKE PT IS VERY TACHYPNEIC WITH AUDIBLE EXP. WHEEZES. AEROSOL COOL MIST MASK ON @ 100%. SATS=96%. ALB/ATR NEBS Q4H. CPT DONE. STRONG NON-PRODUCTIVE COUGH.LUNG SOUNDS CLEAR WHEN PT CALM & SLEEPING.\n\nGI- ABD SOFT. + BS. NO STOOL. TOOK 1 PO MED. WITHOUT DIFFICULTY. REQUIRED CUEING TO SWALLOW.\n\nGU- LASIX 80MG TID. DIURESING WELL AFTER DOSE GIVEN THEN BEGINS TO DRIFT DOWNWARD.\n\nLABS- PENDING.\n\nPAIN-DENIES.\n\nPLAN-CONTINUE TO MONITOR RATE/RHTHYM. DIURESE. MONITOR LABS. PULM HYGEINE. MEDICATE FOR AGIATION AND SAFETY.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-27 00:00:00.000", "description": "Report", "row_id": 1656384, "text": "11p-7a\n\nNeuro: Pt tapping on siderails, admitted to feeling anxious. Admits to \"a couple of scotches a day\". Ativan 0.5mg iv at midnight without much effect. Ativan 1mg given iv at 1am and pt slept for about an hour. Awoke with incisional pain, 1 percocet with effect.\nOriented x3 in beginning of shift but became more agitated, trying to climb out of bed. 4 person lift from bottom of bed. Restraints applied as pt was pulling at lines. Ativan given again without much effect- d/c'd and Haldol started iv, pt sleeping at this time. Moving pretty well in bed, helping with turns.\nCIWA scale started, score 12 at 4am.\n\nCV: BP 88-114/60-90 AF 80-110 with occ bursts to 120's, rare pvc.\nK repleted. Pacer on vdemand 45. +palp pp. Hct 24.7 from 27.7-team aware. EKG done with pt's agitation- looks ok per .\n\nResp: Lungs crackles at bases. Team aware. CXR done, no change from last xray \"wet\". Sats 95-98% on 5L nc. Pa02 71, otherwise abg wnl.\nChest tubes draining minimal.\n\nGI/GU: Abd softly distended. BS hypoactive. MOM given on eves, pt denies flatus. Taking small amts water. Urine output 7-38, amber, team aware. Orders to send urinalysis and flush foley. Due for lasix 8am. Creatnine remains 1.3\n\nSkin: rash to bottom. Bleach free linen ordered by previous shift- implemented. Dressings dry and intact.\n\nSocial: No calls this shift.\n\nPlan: Cont CIWA scale. Medicate prn. Maintain safety. Cont to monitor hemodynamics and respiratory status. Lasix as ordered. Send u/a. Monitor labs, treat prn. Pain control. Reassurance.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-27 00:00:00.000", "description": "Report", "row_id": 1656385, "text": "Respiratory care: Pt seen for neb txs today. Pt developed exertional wheezes vs ? fluid overload. Lung sounds diminished with scatered wheezes with no change after txs. Pt also ordered for MDIs but pt unable to do it, no c/o sob. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-27 00:00:00.000", "description": "Report", "row_id": 1656386, "text": "11A-11P\n\nNEURO: PT. CONFUSED, DISORIENTED, AT TIMES ORIENTED X2 (YEAR AND BIRTHDATE), OOB TO CHAIR AT 1200- BECAME MORE CONFUSED, ATTEMPTING TO GET OUT OF THE CHAIR, PULLED PERIPHERAL IV, BECAME PT. PLACED BACK INTO BED AFTER ONE HOUR (PER TEAM). PUPILS 3MM, EQUAL AND REACTIVE, MAE AND OBEYS COMMANDS AT TIMES. PT. CAN REFUSE CARE AND BECOME UNCOOPERATIVE. PT. RECEIVES 0.5MG PO ATIVAN AS WELL AS PO HALDOL AND TOLERATES DOSE FOR ONE HOUR AND THEN BECOMES QUICKLY CONFUSED AFTER THAT. PT. ON CIWA SCALE- SEE CAREVUE FOR RESULTS.\n\nCV: PT. AFIB, HR 90-100 (WHEN CONFUSED PT. RATE 100-120), SBP 90-120 (WHEN CONFUSED AND AGITATED SBP 130-140-PA NILLSON AWARE), HEPARING GTT STARTED AT 600 UNITS/HR. PTT DRAWN AND RESULT 36-> GTT INCREASED TO 700 UNITS/HR. NEXT PTT LEVEL AT 0300. PULSES PALPABLE.\n\nRESP: PT. LUNGS CLEAR IN UPPER FIELDS WHEN CALM AND COOPERATIVE, BECOMES INSP/EXP WHEEZE WHEN AGITATED AND CONFUSED, ALBUTEROL NEB TREATMENTS GIVEN, PT. DOES NOT COOPERATE WITH MDI'S. OXYGENATION >94% ON 6LNC. CHEST TUBES DC/D THIS AM.\n\nGI/GU/ENDO: PT. ABD SOFT DISTENDED, +BS, TOLERATING REGULAR DIET, FOLEY DRAINING CLEAR, YELLOW URINE- 40MG IV LASIX GIVEN 3X/DAY- 80MG IV LASIX GIVEN AT 1300 FOR RESPIRATORY STATUS, XRAY DONE AS WELL. PT. DIURESING WITH GOOD H/U/O. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. GIVEN ACETAMINOPHEN FOR PAIN- TOLERATING IT.\n\nPLAN: MONITOR NEURO, FREQUENT ORIENTATION, CIWA SCALE MONITORING, AFIB, PTT AT 0300, MONITOR PULMONARY STATUS, PAIN MGT.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-26 00:00:00.000", "description": "Report", "row_id": 1656381, "text": "Neuro: A&O x3, MAE's, following commands consistently; cooperative with care, moan a lot, reassured with pathway post cardiac surgery, calm for a while and started to moan \"Oh dear\", \"Oh boy\", \"this is too much\", took short nap during night\n\nCV: Afebrile; AV paced @ 80, 2A 2V wires, A wires capturing but not sensing d/t slow atrial rate, V wires sensing & capturing; neo increased to 1.1 mcg/kg/min during shift per PA for higher BP for low UO, able to wean to 0.9 mcg/kg/min after transfused 1 unit PRBC, post transfusion hct 27.5; palpable pulses x4, -hematoma around R fem old a line site\n\nResp: Lung sound clear, dim @ bases, received on 100% face mask, weaned to 5L NC later in shift, better oxygenation when sitting up; IS to ~1000, non-productive cough, CT to suction with serousang drainage\n\nGI: Abd soft distended, tolerating pills & clear liquid, hypo bowel sound\n\nGU: Foley draining clear yellow urine, low UO @ beginning of shift, extra 40 mg IV lasix given with minimal effect, UO improved after transfusion and 40mg lasix after, Cr elevated to 1.3 from 0.5, PA awared\n\nInteg: Rash noted on back & lower abdomen, ring appearance on L upper back, lotion applied\n\nPain: c/o pain all over, managed with percocet with good effect\n\nActivity: OOB to chair & back to bed with 2 assist, tolerated well\n\nSocial: Wife called & updated\n\nEndo: Cover per CSRU protocol\n\nPlan: moniotr hemodynamics, resp status, labs; wean neo as tol; monitor renal status; pulm toilet; pain management; inc activity as tol; encourage PO intake\n" }, { "category": "Nursing/other", "chartdate": "2133-08-26 00:00:00.000", "description": "Report", "row_id": 1656382, "text": " 7a-7p\nneuro: a+o x3, mae, follows commands, less anxious than yesterday, up to chair with assist x2, ambulated with assist x 2 x20 feet, tired quickly while ambulating, perrlaa, percocets 2 tab q 4 hr\n\ncv: complete heart block under av pacing per aeg, seen by ep service; continued av pacing to maintain atrial kick, weaning neo gtt to keep sbp by cuff >90, cvp 6-13, art line still inaccurate for bp, afeb\n\nresp: lungs cta, diminished to bases, is to 750ml, moderated strength nonproductive cough, 02 sats >96%\n\ngi: bowel sounds present, tolerating small amounts regular diet, c/o heartburn this pm, protonix given early, pepcid given x1, no insulin needs today\n\ngu: foley to gravity draining clear yellow urine, uop slowing this pm, pm lasix dose given early\n\nassess: stable\n\nplan: increase activity, continue to wean neo, pulmonary toilet\n" }, { "category": "Nursing/other", "chartdate": "2133-08-27 00:00:00.000", "description": "Report", "row_id": 1656383, "text": "1900-2300:\nPt received off gtts, SBP 90's-110's, c/o nausea, 5mg reglan & milk of magnesia given; VSS, c/o pain, managed with PO percocet with good effect; lung sound clear, dim @ bases, palpable pulses x4; a fib in 80's confirmed with AEG, pacer set @ VVI back up @ 40\n" }, { "category": "Nursing/other", "chartdate": "2133-08-25 00:00:00.000", "description": "Report", "row_id": 1656380, "text": " 7a-7p\nneuro: received sedated on precedex, turned off after extubation; a+o x3, mae, follows commands, mild anxiety-pt calmer when people are in room with him, frequent requests for attention/company, perrlaa\n\ncv: av paced 84 this am with what appeared to be junctional underlying rhythm, later aeg showed underlying rhythm to be complete heart block with a ventricular rate of 60, pt able to sustain sbp in 90s on neo gtt while in underlying rhythm, pacer turned to vvi 50 np; no atrial sensing per pacer, but able to av pace or vvi; titrated neo gtt to maintain sbp>90 per nibp (abp inaccurate; fem and right radial art lines d/ced, new art line placed to left radial-also inaccurate, but left in place for blood draws), ct draining serosanguineous drainage; sv02 49-61 (improved with pacing), swan d/ced this pm, max temp 38.3 np aware, percocets continuing, epi d/ced this am with minimal change in ci/co; ci>2.1 throughout shift\n\nresp: lungs cta, diminished to bases, extubated this am at 0710 to nasal cannula and face tent; pt required higher 02 concentration (tent->mask with fi02 100%; nc 4->6L) while fem art line being pulled, 02 sats 93-100%, is 500-750ml moderate strength, non-productive cough\n\ngi: hypoactive bowel sounds, tolerating small amounts clear liquid diet, requesting ice chips/water almost constantly, insulin gtt d/ed this am\n\ngu: foleyt to gravity draining clear yellow urine; uop dropped <30ml/hr multiple times during day shift- lasix ivp given each time with small improvement in uop for short term\n\nlabs: repleted kcl, hct dropped from 28 to 25, np aware, hct drawn this pm-still pending\n\npain: pt c/o pain at all times, though per grimace scale pain appears to range from , percocets given q4h with morphine 2-4mg q2h for breakthrough pain\n\nassess: stable\n\nplan: pulmonary toilet; bedrest until 1900, then increase activity as tolerated, wean neo to maintain systolic bp per cuff>90\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-31 00:00:00.000", "description": "Report", "row_id": 1656395, "text": "neuro: awake alert confused at times- not able to re-direct - given po haldol and ativan with fair effect- found trying to get oob- redirecte4d\nresp: lsc to dim- audible upper airway wheezing noted with agitation- sats good on 4-6l n/c-\ncv: afib- no ectopy- lytes repleted prn- b/p good- pulses good- remains on amio gtt at 1mg/min\ngi/gu: abd soft- bs present- small soft stool x2- foley to gravity- responds well to lasix-\nendo: bg per ss- no coverage needed\nplan: ?- cont to monitor neuro/resp/cv status- cont plan of care\n" }, { "category": "Echo", "chartdate": "2133-08-24 00:00:00.000", "description": "Report", "row_id": 83206, "text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve prolapse. Valvular heart disease. Intraop TEE for Mitral Valve Repair/Replacement\nHeight: (in) 68\nWeight (lb): 191\nBSA (m2): 2.01 m2\nBP (mm Hg): 150/72\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:52\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.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Small secundum ASD.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). [Intrinsic LV systolic function likely depressed given the severity of\nvalvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta 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: Moderate/severe MVP. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting\nbradycardia (HR<60bpm). Results were personally reviewed with the MD caring\nfor the patient.\n\nConclusions:\nThe left atrium is markedly dilated. A small secundum atrial septal defect is\npresent. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). [Intrinsic left\nventricular systolic function is likely more depressed given the severity of\nvalvular regurgitation.] Right ventricular chamber size and free wall motion\nare normal. There are simple atheroma in the descending thoracic aorta. The\naortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. There is moderate/severe\nmitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2133-09-04 00:00:00.000", "description": "Report", "row_id": 225425, "text": "Sinus bradycardia. Marked prolonged P-R interval. Terminal T wave inversions in\nleads V2-V3 are non-specific. The Q-T interval is mildly prolonged. Compared to\nthe previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2133-09-03 00:00:00.000", "description": "Report", "row_id": 225426, "text": "Baseline artifact. Probable sinus rhythm. P-R interval prolongation. Left\natrial abnormality. Q-T interval prolongation with early precordial T wave\ninversions. Since the previous tracing of early precordial T wave\nabnormalities may be more marked.\n\n" }, { "category": "ECG", "chartdate": "2133-08-28 00:00:00.000", "description": "Report", "row_id": 225427, "text": "Junctional rhythm at 56 beats per minute. Slightly prolonged QTc interval.\nCompared with prior tracing of the rhythm is now junctional and\natrial fibrillation is no longer present.\n\n" }, { "category": "ECG", "chartdate": "2133-08-27 00:00:00.000", "description": "Report", "row_id": 225428, "text": "Atrial fibrillation with rapid ventricular response. Modest diffuse ST-T wave\nchanges that are non-specific. Compared to tracing #1 rapid ventricular\nresponse is new. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-08-26 00:00:00.000", "description": "Report", "row_id": 225429, "text": "Atrial fibrillation with moderate ventricular response. Occasional demand\nventricular paced spikes. Compared to tracing of atrial fibrillation\nis now present. There are occasional pacemaker spikes that are new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2133-08-24 00:00:00.000", "description": "Report", "row_id": 225430, "text": "Junctional rhythm\nNonspecific ST-T wave abnormalities\nSince previous tracing of , junctional rhythm now present and ST-T wave\nchanges appear slightly less prominent\n\n" }, { "category": "ECG", "chartdate": "2133-08-23 00:00:00.000", "description": "Report", "row_id": 225661, "text": "Normal sinus rhythm. A-V conduction delay. ST segment depressions in the\nanterior and lateral leads of one millimeter suggestive of possible anterior\nand anterolateral ischemia. Clinical correlation is suggested. Compared to\nthe prior tracing #1 the anterior and anterolateral ST segment depressions are\nnew.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-08-21 00:00:00.000", "description": "Report", "row_id": 225662, "text": "Normal sinus rhythm. Early R wave transition. No previous tracing available\nfor comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2134-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199462, "text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: bleed?\n Admitting Diagnosis: PACER EROSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with pacer pocket infection s/p explant with wire removal and\n temporary pacemaker placement\n REASON FOR THIS EXAMINATION:\n bleed?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:38 A.M., \n\n HISTORY: Pacer pocket infection following explant with wire removal and now\n temporary pacemaker.\n\n IMPRESSION: AP chest compared to :\n\n There is no pneumothorax, appreciable pleural effusion, or mediastinal\n widening. Transvenous lead extends from the left supraclavicular pacemaker to\n the right ventricular apex. Moderately enlarged cardiac silhouette is\n slightly smaller today, with a configuration indicating a very dilated left\n atrium, but there is no pulmonary vascular congestion or edema. Shunt\n catheter traverses the right neck, chest, and upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-07-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1200158, "text": " 8:36 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p right-sided permanent pacemaker implant. ? lead placemen\n Admitting Diagnosis: PACER EROSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with h/o chb s/p right-sided ppm placement.\n REASON FOR THIS EXAMINATION:\n s/p right-sided permanent pacemaker implant. ? lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with right-sided permanent pacemaker placement. Please\n assess lead placement and pneumothorax.\n\n COMPARISON: Chest radiograph from , and .\n\n FINDINGS: Pacemaker is observed in the right axillary area with leads ending\n in standard positions in the right atrium and the right ventricle. No\n evidence of pneumothorax. Good lung volumes without focal radiopacities.\n Mild-to-moderate cardiomegaly is present. New small bilateral pleural\n effusions with concurrent mild left basilar atelectasis has developed since\n prior exam. A ventriculoperitoneal shunt is seen tracking along the midline.\n\n IMPRESSION: Interval development of small bilateral pleural effusions with\n left base atelectasis. New pacemaker with leads in standard position.\n\n" }, { "category": "Radiology", "chartdate": "2134-07-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1199426, "text": " 7:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New pacer line stability, PTX?\n Admitting Diagnosis: PACER EROSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p pacer removal, external pacer placement.\n REASON FOR THIS EXAMINATION:\n New pacer line stability, PTX?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:35 P.M. ON \n\n HISTORY: External pacer placement. Assess position and possible\n pneumothorax.\n\n IMPRESSION: AP chest compared to . Lung volumes are appreciably lower\n today, and presumably that affects the shape and size of the cardiac\n silhouette. In the absence of mediastinal vascular engorgement, I do not\n believe this represents an acute pericardial effusion. A solitary transvenous\n right ventricular lead follows the expected course from a pacemaker projected\n over the left supraclavicular region. There is no mediastinal widening,\n pneumothorax, or pleural effusion. Lungs are essentially clear, and pulmonary\n vasculature is not engorged. A right shunt line runs from the neck across the\n chest to the upper abdomen and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2134-07-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1198298, "text": " 10:48 PM\n CHEST (PA & LAT) Clip # \n Reason: ? wire placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with pacer eroding through her chest wall\n REASON FOR THIS EXAMINATION:\n ? wire placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pacer eroding through the chest wall, question wire placement.\n\n TECHNIQUE: PA and lateral radiographs of the chest.\n\n COMPARISONS: None available.\n\n FINDINGS: Pacer box is seen in the left anterior chest wall which is tilted,\n is compatible with clinical exam, findings which demonstrate the lateral\n portion of the box is eroding through the skin. The wires appear slightly\n coiled near the box with abnormal appearance of the right atrial lead which\n appears to be retracted and projecting superiorly and anteriorly. The left\n ventricular pacer lead appears in appropriate position. The lungs are clear\n without focal opacity, pleural effusion, or pneumothorax. The heart is normal\n in size. Normal cardiomediastinal silhouette, and VP shunt is noted coursing\n along the anterior soft tissues of the chest.\n\n IMPRESSION: Slightly aberrant positioning of the right atrial lead could\n relate to retraction secondary to pacer box eroding through skin.\n\n\n" }, { "category": "Echo", "chartdate": "2134-07-22 00:00:00.000", "description": "Report", "row_id": 91279, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Evaluate aortic stenosis. S/P permanent pacemaker placement.\nHeight: (in) 67\nWeight (lb): 129\nBSA (m2): 1.68 m2\nBP (mm Hg): 122/69\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:20\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\ns/p perm pacemaker insertion with removal of prior pacemaker infected lead.\nLEFT ATRIUM: Elongated LA.\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. Normal IVC diameter\n(<=2.1cm) with >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction. Paradoxic septal motion consistent with conduction\nabnormality/ventricular pacing.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\nvegetations on aortic valve. Severe AS (area 0.8-1.0cm2). Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Probable\nvegetation on tricuspid valve. Moderate [2+] TR. Borderline PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 0-5 mmHg. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Right ventricular chamber size\nis normal. with borderline normal free wall function. The diameters of aorta\nat the sinus, ascending and arch levels are normal. The aortic valve leaflets\nare moderately thickened. No masses or vegetations are seen on the aortic\nvalve. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. No mass or vegetation is seen on the mitral valve. Mild\n(1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is a small, independently moving echodense structure\nmeasuring 0.2 x 0.4 centimeters in greatest dimension (clip , 104) on the\n?posterior leaflet of the tricuspid valve concerning for possible vegetation\nvs a torn chordae. At least moderate [2+] tricuspid regurgitation is seen.\nThere is borderline pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity\nsize and preserved global and regional left ventricular systolic function.\nPossible tricuspid valve vegetation with at least moderate tricuspid\nregurgitation as described above. Severe aortic stenosis with mild to moderate\naortic regurgitation.\n\nTo futher characterize the possible tricuspid valve vegetation a\ntransesophageal echocardiogram may be considered.\n\nDr. notified of the results by phone.\n\n\n" }, { "category": "Echo", "chartdate": "2134-07-15 00:00:00.000", "description": "Report", "row_id": 91325, "text": "PATIENT/TEST INFORMATION:\nIndication: lead extraction\nHeight: (in) 67\nWeight (lb): 123\nBSA (m2): 1.65 m2\nStatus: Inpatient\nDate/Time: at 16:02\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\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\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch. Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\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 under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\nrhythm appears to be atrial fibrillation. Results were personally reviewed\nwith the MD caring for the patient.\n\nConclusions:\n\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. No atrial septal defect is seen by 2D or color\nDoppler.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are focal calcifications in the aortic arch. There are simple atheroma\nin the descending thoracic aorta. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area\n<0.8cm2). Mild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen.\nThere is no pericardial effusion.\nThis new finding was conveyed to Dr. during the lead placement.\n\n\n" }, { "category": "ECG", "chartdate": "2134-07-21 00:00:00.000", "description": "Report", "row_id": 247803, "text": "Atrial fibrillation and ventricular paced rhythm with capture, new as compared\nto the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2134-07-16 00:00:00.000", "description": "Report", "row_id": 247804, "text": "Underlying atrial fibrillation with probable junctional escape beats\nat 50 beats per minute with diffuse T wave inversions which are non-specific\nand there is marked Q-T interval prolongation. Compared to the previous\ntracing of ventricular pacing is no longer present and the junctional\nescape rhythm is new.\n\n" }, { "category": "ECG", "chartdate": "2134-07-14 00:00:00.000", "description": "Report", "row_id": 247805, "text": "Ventricular paced rhythm with underlying atrial fibrillation. Compared to the\nprevious tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2134-07-07 00:00:00.000", "description": "Report", "row_id": 247806, "text": "Ventricularly paced rhythm. Underlying rhythm is probably atrial fibrillation.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2113-07-14 00:00:00.000", "description": "Report", "row_id": 100146, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 200\nBSA (m2): 1.94 m2\nBP (mm Hg): 133/37\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 15:54\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 report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta 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. Moderate\nmitral annular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic 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.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is borderline pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the findings are similar.\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": "2113-07-19 00:00:00.000", "description": "Report", "row_id": 275798, "text": "Atrial fibrillation with a rapid ventricular response, new as compared to the\nprevious tracing of .\n\n" }, { "category": "ECG", "chartdate": "2113-07-14 00:00:00.000", "description": "Report", "row_id": 275799, "text": "Normal sinus rhythm. Borderline short P-R interval and occasional premature\natrial contractions. Compared to tracing #1 no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2113-07-13 00:00:00.000", "description": "Report", "row_id": 275800, "text": "Normal sinus rhythm with frequent premature atrial contractions. Low limb lead\nvoltage. Borderline short P-R interval. Compared to the previous tracing\nof the frequent atrial premature beats are new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2113-07-17 00:00:00.000", "description": "CENTRAL NON-TUNNELED", "row_id": 916539, "text": " 9:56 AM\n DIAL CHECK/REPO Clip # \n Reason: please change Quinton to Quinton with VIP port (trialysis) f\n Admitting Diagnosis: SHORTNESS OF BREATH\n ********************************* CPT Codes ********************************\n * CENTRAL NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PEs, MG, had Quinton line placed for plasmapheresis.\n Need access, pls change line over wire to Quinton with VIP Port.\n\n REASON FOR THIS EXAMINATION:\n please change Quinton to Quinton with VIP port (trialysis) for access with\n blood draws\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old woman with PE, NG, and in situ pheresis catheter.\n Requires further IV access.\n\n PHYSICIANS: Dr. and Dr. with Dr. , the\n attending radiologist, supervising.\n\n PROCEDURE: After informed consent, the patient was positioned supine on the\n angiography table. A preprocedure timeout was performed to confirm patient,\n procedure, and site. Standard sterile prep and drape of the right base of the\n neck and in situ double-lumen pheresis catheter. Local anesthesia with 6 cc\n of 1% lidocaine subcutaneously. The retaining sutures were cut. The Hep-Lock\n was aspirated from the catheter. A 0.035-inch guidewire was advanced through\n the catheter into the inferior vena cava using fluoroscopic guidance. Over\n the guidewire, the catheter was exchanged for a new 12-French 16-cm triple-\n lumen pheresis catheter and the tip was positioned in the superior vena cava.\n The guidewire was removed. All three lumens of the catheter flushed and\n aspirated well, were capped, and heplocked. The catheter was sutured in place\n with 2-0 silk sutures and a sterile transparent dressing was applied. Final\n limited chest radiograph confirmed catheter tip position in the superior vena\n cava. Five sternotomy wires are present and their positions are similar to\n prior radiograph of and .\n\n The catheter can be used immediately.\n\n There were no immediate complications.\n\n IMPRESSION: Successful exchange of the in situ double-lumen pheresis\n catheter, which was removed in its entirety for a new triple-lumen 12-French\n 16 cm pheresis catheter with tip in the superior vena cava. The catheter can\n be used immediately.\n (Over)\n\n 9:56 AM\n DIAL CHECK/REPO Clip # \n Reason: please change Quinton to Quinton with VIP port (trialysis) f\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2113-07-13 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 916119, "text": " 10:08 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE?\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with myasthenia , tachycardia, and low PO2 at pulm\n clinic yesterday.\n REASON FOR THIS EXAMINATION:\n PE?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:19 PM\n bilateral pulmonary emboli, on the right involving the right main pulmonary\n artery.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Myasthenia , tachycardia, hypoxia, evaluate for PE.\n\n COMPARISON: CT of the chest from .\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed after the\n administration of intravenous contrast. Multiplanar reformations were\n obtained.\n\n FINDINGS: There are filling defects in the right main pulmonary artery, as\n well as right segmental pulmonary arteries of the lower and upper lobes. In\n addition, there are filling defects in the left upper lobe segmental pulmonary\n arteries. As well as the left lower lobe segmental arteries. The aorta is of\n normal caliber with some atherosclerotic calcifications. The heart and\n pericardium appear unremarkable. There is some dependent atelectasis in the\n lungs. As well as a calcified 2 mm nodule in the right upper lobe. Airways\n are patent to the level of the segmental bronchi bilaterally. No pathologic\n axillary, mediastinal, or hilar lymphadenopathy is identified.\n\n In the visualized upper abdomen, the superior aspect of the liver, spleen,\n stomach, pancreas, left kidney appear unremarkable.\n\n The osseous structures demonstrate multiple compression deformities of the\n thoracic spine which appear unchanged. The patient is status post median\n sternotomy.\n\n IMPRESSION: Bilateral pulmonary emboli, involving multiple segmental\n pulmonary arteries as well as the right main pulmonary artery.\n\n Compression deformities of the thoracic spine as seen on prior studies.\n\n Findings conveyed to the emergency department dashboard.\n\n (Over)\n\n 10:08 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE?\n Field of view: 38 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2113-07-14 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 916148, "text": " 7:44 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: assess LE for DVTs\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with bilateral PEs\n REASON FOR THIS EXAMINATION:\n assess LE for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with bilateral pulmonary embolus.\n\n COMPARISONS: None.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: scale and Doppler son of the\n bilateral common femoral, greater saphenous, superficial femoral, and\n popliteal veins were performed. Normal flow, waveforms, augmentation, and\n compressibility were demonstrated. No intraluminal thrombus identified. A\n 3.6 x 2.8 x 2.0 cm ovoid fluid collection in the left posterior knee is\n consistent with cyst.\n\n IMPRESSION: No evidence of bilateral lower extremity DVT. 3.6 cm cyst\n in the left popliteal fossa.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-15 00:00:00.000", "description": "NON-TUNNELED", "row_id": 916327, "text": " 12:07 PM\n PHERESIS CATHETER PLMT Clip # \n Reason: please place line for plasmapheresis\n Admitting Diagnosis: SHORTNESS OF BREATH\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PEs, MG\n REASON FOR THIS EXAMINATION:\n please place line for plasmapheresis\n ______________________________________________________________________________\n FINAL REPORT\n PHERESIS CATHETER\n\n INDICATION: 81-year-old woman, needs plasmapheresis.\n\n Details of the procedure and possible complications were explained to the\n patient and informed consent was obtained.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist, was\n present for the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia the right internal\n jugular vein was accessed with a micropuncture set under direct ultrasound\n guidance. A micropuncture sheath was then exchanged for serial dilators over\n the wire and a pheresis catheter was then placed with the tip positioned in\n SVC under fluoroscopic guidance. The catheter was secured to the skin.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n No conscious sedation medications were given to the patient.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided pheresis\n catheter placement via the right internal jugular vein approach with the tip\n positioned in SVC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-07-15 00:00:00.000", "description": "Report", "row_id": 1437667, "text": " nsg note: 19:00-7:00\nthis is an 81 y.o. woman adm with hx myasthenia dx in ', copd, thymus resection in ', s/p plasmapheresis in ' and . pt was adm for progressive sob over the last 3 wks, was sent to the er by her pulmonologist who saw her in clinic with pa02 of 56 with 02 sats in the 80s. in er, pt's sat was in the low 90s on rm air and 95% on 2lnc. a ct angiogram revealed bilat pe's and pt was given bolus and started on gtt until am labs with ptt>150 and gtt was stopped at 8am. pt given a dose of lovenox and was restarted on gtt at 11pm md gtt stopped at 2:30am md for pheresis catheter to be placed this am. will draw am labs at 6 md.\n\nneuro: a&ox3, mae, requires 2 assist with repositioning. follows commands. slept most of the shift but arousable.\n\ncv: hr ranging 60s-80s sr with occas pvcs and apcs noted. bp ranging 120s-140s/40s-50s. +weak pp. 2+ pedal edema with le's remaining with baseline erythema.\n\nresp: 02 sat 93-100% on 2lnc. placed on bipap at 10pm on 10 IPAP and 5 EPAP with 1 liter nc. desated to 85% while asleep on bipap and woken up with sats up to 95%. desated again to 85% even when taking deep breaths and 02 increased to 2lnc with sats up to 96%.\n\ngi/gu: abd obese, soft, nt/nd, +bs, denies nausea. small bm loose brown in yellow urine pt voiding in bedpan.\n\nskin: extremities with mult. bruised areas and skin appearing paper thin and very fragile. paper tape used with blood draw. lower ext with baseline erythema.\n\nlines: l ant piv #20g patent.\n\nsocial: pt spoke to family on phone early in the shift. pt was made a dnr/dni yesterday.\n\nplan: f/u with am labs. pheresis catheter to be placed today and pt to then have pheresis. pt will need to be restarted on anticoagulation after the pheresis catheter placed. pneumoboots ordered. please apply to pt when available. pt cleared to wear them by md team as her LENIs from yesterday were negative. monitor lytes and replete prn.\n" }, { "category": "Nursing/other", "chartdate": "2113-07-15 00:00:00.000", "description": "Report", "row_id": 1437668, "text": "see previous note for hx:\n\nneuro: pt A&O< moving upper extremities but little ability to move legs d/t inc size and weakness from arthritis. weakness in hands d/t arthritis. no pain other than new rt subclav phresis cath\n\ncv: few pac's nsr rate 80-90. bp stable. aline polaced for blopod draw at 1700. skin warm and red. good perph pulses\n\nresp: multiple emboli seen on initial xray and pe not consistent with MG diagnosis but prob d/t other probs. pt was off hep at 0230 and restarted 0920 to 1040 at 1200 units/hr. then stopped for IR intervention. plasma phresis done at 1300-1500 and this will effect\nthe clotting facxtors and inc ptt. not restarted until ptt baseline back 1800 and then confer with team. dosing will be very complicated and unable to follow protocol. sat improved all day to 100% on 2 l nc. pt using pursed lip breathing with COPD hx. ? need for bipap at night . lungs clear.\n\ngi: sm soft brown stool hem neg this am. po intake house diet adequate\npos bs\n\ngu: pt hx inc and inc lg amts x3-4 times today. pt given bedpan but voids over and around. diaper applied 625 in and 1075 out\n\nskin: multiple ecymotic areas no breakdown\n\naccess: new pheresis line with very lg exit site oozing and dsg changed x2 since placed. pt may need suture at site and /or press with surgisorb at bedside. lt anticub PIV for hep and a-line for freq bld draw all patent\n\nplan: pheresis qod for total 5 tx anto correct antibodies [poss effecting resp depression associated with MG and needs careful anticoagulation for PE. monitor resp status and bleeding from rt subclav line\n\n" }, { "category": "Nursing/other", "chartdate": "2113-07-16 00:00:00.000", "description": "Report", "row_id": 1437669, "text": "Nursing Assessment NOte 1900-0700\nNEURO: Pt A&O x3, pleasant and cooperative, pt moves all extremities well without deficit and is mostly independent with repositioning, PERRL,\n\nCV: Pt's vss, afebrile, pt denies pain at this time, Pt has right radial A-line, waveform is sharp and wnl, pt also has #20 in left arm, with drip infusing @ 500 units/hour, ptt is due q4 hours on 6, 10, 2 schedule and wil be titrated by each result, Skin is pale, warm, and dry, pp + & =, with +1 - +2 generalized edema, pt in nsr without ectopy\n\nRESP: Pt's lung sounds are clear, pt denies sob or cough at this time, Pt on O2 @ 2 L v/NC with sats 97-99%, pt refused to use Bipap during night tonight, but will call for it should she feel she needs it\n\nGI: Pt tol po intake well without N/V, bowel sounds are positive, with softly distended abd, Pt has had no stool at this time\n\nGU: Pt voids clear yellow urine qs, pt also is inc of urine throughout my shift\n\nPLAN:\n-COnitnue with drip and monitor PTT's q4 hours\n-Continue to provide O2 support as needed\n-? monday as next phersis treatment\n" }, { "category": "Nursing/other", "chartdate": "2113-07-16 00:00:00.000", "description": "Report", "row_id": 1437670, "text": "Respiratory Care:\nPts NIF = 34 and VC = 700cc. appears comfortable on nasal cannula at 2L/M. Declined to use BiPap last noc complaining of stress and fatigue.? if she will use tonoc..\n" }, { "category": "Nursing/other", "chartdate": "2113-07-14 00:00:00.000", "description": "Report", "row_id": 1437665, "text": " nsg note: 19:00-7:00\nthis is an 81 y.o. woman adm with hx myasthenia dx in ', copd, thymus resection in , s/p plasmapheresis in ' and . pt was adm for progressive sob over the last 3 wks sent in to er by her pulmonologist who saw her in clinic with pa02 of 56 with 02 sats in the 80s. in er, pt's sat was in the low 90s on rm air and 95% on 2lnc. a ct angiogram revealed bilat pe's and pt was given 6000 unit bolus heparin and started on heparin gtt at 12am at 1600units/hr. will draw 6am inr and k.\n\nneuro: a&ox3, mae, cooperative with care and following commands. requires max with adl's.\n\ncv: hr ranging 80s-90s sr with no ectopy noted. bp ranging 120s-130s/80s. +weak pp. 2+ pedal edema. ext sl cool to touch which pt states is baseline for her.\n\nresp: lungs cta, sp02 ranging 99-100% on 4lnc. denies sob at rest but states she does get winded with increased activity. pta she noticed she was only walking 4 feet at home instead of her usual 10 feet.\n\ngi/gu: abd obese, soft, nt/nd, +bs, denies nausea, no bm. incontinent urine in er. no void yet.\n\nskin: intact. lower ext with bruised areas.\n\ncomfort: denies pain.\n\nlines: l ant piv #20g patent. unable to place 2nd piv, team aware.\n\nplan: f/u with 6am ptt and k. heparin gtt per ss, monitor resp status closely, continue prednisone, mestinon.\n" }, { "category": "Nursing/other", "chartdate": "2113-07-14 00:00:00.000", "description": "Report", "row_id": 1437666, "text": "ALTERED RESP STATUS\nd: neuro: pt pleasant. alert x3 and cooperative. generalized weakness of her extremities and pt needs assist of 2 people with turning. neurophysiology fel;low by to evaluate pt and because of her low nif and vc documented by resp therapist this afternoon and fatiguable deltoid muscle it is felt that pt still ahs reps dysfunctione due to her myasthenia . pt had been started on lovenox this am but because of these findings the plan is to restrt the heparin gtt tonoc at 2200 and d/c at some as of yet undetermined time so that a plasmaphoresi cath can be placed and pt can undergo palsmaphoresis tomorro. pt has been called out to medical floor but this is now on hold.\n\nresp: pt with o2 at 2l/m nc and ct pos for multiple pulm embolis bil. occasional scattered wheezes noted otherwise clear on auscultation. hr rr has been in the 20's and her o2 sats have remained > 97%. may attempt bipap trials overnoc. will conitnue to check nif's and vc 's as ordered. pt appears comfortable at rest but with exertion pt sob and with pursed lip breathing. continue to follow resp status closely.\n\ncv: hr has been in the 80-90's without ectopy and sbp has ranged from 114-145. continue to follw electolytes as ordered and replete as needed.\n\ngi: abd soft and nontender with pos bowel sounds on auscultation. tolerating reg diet with good appetite and no c/o n/v. no stool output this shift.\n\n\ngu: pt receives lasix 20 ng po qd and has been using bedpan for voiding.\n\nid: no active id issues.\n\n\nsocial: discussion held with pt regarding her code status and pt has made herself dnr/dni. will continue with present medical management and keep pt and family well informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-07-16 00:00:00.000", "description": "Report", "row_id": 1437671, "text": "7AM-7PM Nsg Progress Note\n82 y.o female with myasthenia and bilat PE's\n\nRESP: pt remains on 2 n/p, rr~20's O2 sats 94-96% lungs clear, no c/o SOB NIF 34 VC 700 to have plasma pheresis in am.\n\nCV: bp stable 122/62 HR 90's SR no vea noted.\n gtt continues, increased to 600 u/hr (PTT 47.0)\n\nGI: tolerating House diet, sm brown bm guiac negative. pt using commode with 1-2 assists.\n\nGU: voiding in commode, clear yellow urine.\n\nNEURO: A+Ox3, pleasant and cooperative. OOB to chair all afternoon, wants to stay up. PERRLA.\n\nACCESS: right radial A-line (dsg changed - intact), RIJ pheresis line (dsg changed - intact) left antecubital IV - dsg changed. to be changed in am. IV team stopped by - ? PICC line - will check in am.\n\nPLAN: pheresis in am, check PTT q 4 hrs and adjust gtt accordingly. O2 support, OOB to chair. Resp to check NIF and VC .\n" }, { "category": "Nursing/other", "chartdate": "2113-07-17 00:00:00.000", "description": "Report", "row_id": 1437672, "text": "Nursing Assessment NOte 1900-0700\nNEURO: Pt A&O x3, pleasant and cooperative, PT moves all extremities well without deficit and transfers to commode and chair with 1 assist with fairly steady gait, PERRL\n\nCV: Pt's vss, afebrile, pt denies pain at this time, Skin is pale, warm and dry, pp + & =, with +2- +3 generalized edema, Pt has #20 in left arm with @ 700 units/hour, Ptt's are due q4 hours and will decrease by approx 40% around 0600 for pt's phersis due later today, Pt also has right radial A-line, waveform is sharp and wnl\n\nRESP: Pt's lung sounds are clear, pt denies sob or cough at this time, pt denies need for Bipap during night at htis time, Pt on O2 @ 2 L v/NC, with sats 97-99%\n\nGI: Pt tol po intake well without N/V, bowel sounds are positive, with softly distended abd, Pt had 1 small loose stool on my shift\n\nGU: Pt voids in commode clear yellow urine qs\n\nPLAN:\n-Pt due for Phersis today and plan is to have 4 more treatemnts\n-Have team change phersis cath over wire to one with an infusion port and then D/C a-line and pt can move out to floor\n-Continue drip and check ptt's q4 hours\n" }, { "category": "Nursing/other", "chartdate": "2113-07-17 00:00:00.000", "description": "Report", "row_id": 1437673, "text": "d: pt awake alert and oriented x 3.pt states her strength has improved since she has started her plasamphoresis tx's. pt transported to ir and had new plasmaphoresis cath placed over guidewire. pt tolerated plasmaphoresis. gtt infusing at 400u/hr and repeat ptt drawn at 1800. pt with occasional wheezes on auscultation so pt has been statrted on nebs. o2 at 2l/m nc with o2 sats>97%. pt continues to receive lasix 20 mg po qd as ordered. plan is to transfer to medical bed when one is avaialble. will continue with present medical management and keep pt well informed on a daily basis\n" }, { "category": "Nursing/other", "chartdate": "2113-07-17 00:00:00.000", "description": "Report", "row_id": 1437674, "text": "Resp Care\n\nPt followed by respiratory for bronchodilators Q6 and to assess neuromuscular status daily. Nif/VC stable and consistent with previous measurements. Alb/Atro nebs given via HHN Q6 with stable HR t/o tx. BS essentially clear with no wheezes appreciated. Will cont to mmonitor.\n" } ]

[ { "category": "Radiology", "chartdate": "2134-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238937, "text": " 8:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change and infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with lung ca and recent PNA, now septic\n REASON FOR THIS EXAMINATION:\n assess for interval change and infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Lung cancer and recent pneumonia, now septic.\n\n Comparison is made with prior study, .\n\n Cardiomegaly is unchanged. Right perihilar mass is unchanged. There is\n increase in atelectasis in the right lower lobe. Opacities in the left lower\n lobe have increased; this could be due to atelectasis or pneumonia in the\n appropriate clinical setting. There is no pneumothorax. Right Port-A-Cath is\n in standard position.\n\n" }, { "category": "Radiology", "chartdate": "2134-03-31 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1238965, "text": " 3:16 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for free air, concern for rupture\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with 78 yo man with NSCLC on paclitaxel/carboplatin (last dose\n ) transferred to for persistent hypoglycemia, hypotension and\n tachycardia found to be c.diff positive.\n REASON FOR THIS EXAMINATION:\n Please evaluate for free air, concern for rupture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for free intraperitoneal air.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Single supine upright abdominal radiographs demonstrate gas-filled\n colon and stomach. There is no evidence of free intraperitoneal air. Again\n seen are left lower lobe opacities, similar in appearance to chest radiograph\n from .\n\n\n" }, { "category": "Radiology", "chartdate": "2134-03-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1238817, "text": " 8:40 PM\n CHEST (PA & LAT) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 78M with fever, neutropenia\n REASON FOR THIS EXAMINATION:\n pna?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Fever and neutropenia.\n\n TECHNIQUE: AP radiograph was obtained.\n\n COMPARISON: .\n\n REPORT.\n\n There is patchy bilateral opacity on the right side, representing the\n patient's known tumor. There is also some left retrocardiac and left\n costophrenic opacification, but these are markedly improved from the prior\n study. There is no definitive acute cardiopulmonary finding. Visualized\n osseous structures appear normal. Port remains in good position. There is\n multilevel mid thoracic degenerative change.\n\n CONCLUSION:\n\n Little interval change from prior study.\n\n" }, { "category": "Echo", "chartdate": "2134-04-01 00:00:00.000", "description": "Report", "row_id": 93808, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for pericardial effusion. Tachycardia and hypotension. (Hx NSCLC).\nHeight: (in) 63\nWeight (lb): 194\nBSA (m2): 1.91 m2\nBP (mm Hg): 104/48\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 09:40\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: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No 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 ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded. No echocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF 65%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThe aortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal. There is a small posterior\npericardial effusion. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. There is an anterior space which most\nlikely represents a prominent fat pad. There are no echocardiographic signs of\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of ,\n\n\n" }, { "category": "Radiology", "chartdate": "2134-03-31 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1239050, "text": " 4:06 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for megacolon, ?incarcerated hernia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with known hernia, p/w sepsis, elevated lactate, and severe\n cdif\n REASON FOR THIS EXAMINATION:\n eval for megacolon, ?incarcerated hernia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAb WED 8:07 PM\n 1. Left inguinal hernia contains a large amount of fat, as before, but now\n there is fluid layering within the hernia with stranding of the fat,\n concerning for infarction of the herniated fat. 2. Pancolitis without evidence\n for megacolon. 3. Aortic valve calcification. 4. Bilateral pleural effusions,\n right greater than left, with adjacent atelectasis. Discussed with Dr. \n by phone at 8:05 p.m. on at time of initial review of the study.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 70-year-old male with known hernia presenting with sepsis,\n elevated lactate and severe C. diff. Evaluate for megacolon or incarcerated\n hernia.\n\n COMPARISON: AXR ; abdominal ultrasound ; PET-CT .\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness with oral contrast only.\n No intravenous contrast was administered due to lack of intravenous access.\n Coronal and sagittal reformats were displayed with 5-mm slice thickness.\n\n CT ABDOMEN: There is a small-to-moderate nonhemorrhagic right pleural\n effusion and small left pleural effusion with adjacent compressive\n atelectasis. Supervening infection cannot be excluded on this study. A 9 x\n 16 mm focus in the right middle lobe adjacent to the fissure (2:6) may be\n atelectasis or a small focus of infection.\n\n Evaluation of the intra-abdominal organs is limited without intravenous\n contrast. The unenhanced liver is normal. The gallbladder is distended\n without radiopaque gallstones. The spleen, pancreas and left adrenal gland\n are normal. A calcified focus at the right adrenal gland is unchanged from\n . There is no hydronephrosis. A 1.7 x 1.5-cm indeterminant lesion\n at the left renal superior pole was not FDG-avid on recent PET-CT and is\n unchanged (2:30). An adjacent exophytic hypodensity in the left renal superior\n pole (2:27) is a simple cyst.\n\n There is diffuse wall thickening throughout the large bowel with hyperemia,\n indicated by increased adjacent vessels, and stranding compatible with colitis\n in the ascending, transverse and descending colons. No evidence of toxic\n megacolon. The abdominal aorta is of normal caliber throughout. An IVC filter\n is in place. Mesenteric and retroperitoneal lymph nodes are not enlarged by\n CT size criteria. Mesenteric stranding is nonspecific in the setting of mild\n (Over)\n\n 4:06 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for megacolon, ?incarcerated hernia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n anasarca. There is no free intraperitoneal air.\n\n CT PELVIS: Wall thickening in the rectum and sigmoid colon are compatible\n with colitis. The bladder is decompressed with a Foley catheter in place.\n The prostate is normal. There is no pelvic or inguinal lymphadenopathy. A\n large fat-containing inguinal hernia now contains layering fluid, but no bowel\n is seen within it. A superficial subcutaneous 1.3-cm nodule at the left\n gluteus (2:88) is likely a sebaceous cyst.\n\n BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.\n Multilevel degenerative changes noted.\n\n IMPRESSION:\n 1. Pancolitis without evidence of megacolon.\n 2. Left inguinal fat-containing hernia, with new layering fluid, but no\n bowel. The fluid is nonspecific in the setting of diffuse anasarca, but could\n represent infarction of the herniated fat in the appropriate clinical setting.\n 3. Bilateral pleural effusions, right larger than left with adjacent\n atelectasis. Supervening infection is not excluded. A small focus in the\n right middle lobe adjacent to the fissure may represent atelectasis or focal\n infection.\n 4. Indeterminant left renal lesion is unchanged from and was not\n FDG-avid on . This may represent a proteinaceous or hemorrhagic\n cyst. If clinically indicated, this could be further evaluated by renal\n ultrasound.\n\n Dr. discussed preliminary findings with Dr. by phone at 8:05\n p.m. on at time of initial review of the study.\n\n" }, { "category": "Radiology", "chartdate": "2134-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239091, "text": " 9:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, ?effusions\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with NSCLC p/w sepsis, with more increased crackles on exam\n REASON FOR THIS EXAMINATION:\n interval change, ?effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Non-small cell lung cancer and sepsis, increased crackles,\n evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the right perihilar mass is\n unchanged. At the periphery of the mass, however, there is an area of diffuse\n opacity that has newly occurred and could represent either early pneumonia or\n atelectasis. Short-term followup is required.\n\n Size of the cardiac silhouette is unchanged. Moderate retrocardiac\n atelectasis. Changed appearance of the left lung and of the right internal\n jugular vein catheter.\n\n\n" }, { "category": "ECG", "chartdate": "2134-04-05 00:00:00.000", "description": "Report", "row_id": 248720, "text": "Sinus rhythm with atrial premature beats. Prior inferior myocardial\ninfarction. Non-specific lateral ST-T wave changes. Compared to tracing #1\nthe heart rate is increased. The other findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2134-04-04 00:00:00.000", "description": "Report", "row_id": 248721, "text": "Sinus tachycardia with atrial premature beats. Prior inferior myocardial\ninfarction, age undetermined. Anterolateral ST-T wave changes may be due to\nischemia. Clinical correlation is suggested. Compared to the previous tracing\nof leads V1 and V3 appear to be in normal position. Artifact is now\npresent. THe heart rate is increased. Lateral ST-T wave changes are more\napparent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2134-03-30 00:00:00.000", "description": "Report", "row_id": 248937, "text": "Sinus rhythm. Leads V3 and V1 are likely interchanged. There is low\nprecordial lead voltage and diffuse ST-T wave changes. Left atrial\nabnormality. Compared to the previous tracing of the rate has slowed.\nVentricular ectopy is absent. A repeat tracing of diagnostic quality is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2134-03-30 00:00:00.000", "description": "Report", "row_id": 248938, "text": "Sinus tachycardia. Left atrial abnormality. Occasional ventricular ectopy.\nPrior inferior myocardial infarction. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2127-09-09 00:00:00.000", "description": "BX-NEEDLE LIVER BY RADIOLOGIST", "row_id": 975847, "text": " 10:42 AM\n BX-NEEDLE LIVER BY RADIOLOGIST; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)\n Reason: Ultrasound guided Liver Bx. for transamitis. for MON\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with hx of autonomic dysfunction, dystonia, gastroparesis,\n here for transamitis, which was trending down, but now is increasing again.\n REASON FOR THIS EXAMINATION:\n Ultrasound guided Liver Bx. for transamitis. for MONDAY. thanks\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED LIVER BIOPSY:\n\n CLINICAL HISTORY: 34-year-old woman with history of autonomic dysfunction,\n dystonia, gastroparesis, here for transaminitis, which was trending down but\n now is increasing again.\n\n After explaining the risks and benefits to the patient a written informed\n consent was obtained. A final timeout was completed verifying three patient\n identifiers. The abdomen was marked, prepped and draped in standard sterile\n fashion. Approximately 10 cc of lidocaine was used for local anesthesia.\n\n The patient also received 5 mg of Valium on the floor prior to coming down for\n the procedure. The patient received 1 mg of morphine sulfate intravenously\n during the procedure. The patient patient was continuously monitored by a\n registered nurse throughout the procedure as well as for three hours following\n the procedure.\n\n A 16-gauge core biopsy system was used to obtain one core biopsy from the\n right lobe of the liver. The patient tolerated the procedure well. No\n immediate complications occurred.\n\n The radiology attending, Dr. , was present and supervised the entire\n procedure.\n\n IMPRESSION: Successful ultrasound-guided core biopsy of the right lobe of the\n liver.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-08-27 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 974314, "text": " 10:09 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP films for review\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with biliary colic and abnormal LFT's\n REASON FOR THIS EXAMINATION:\n ERCP films for review\n ______________________________________________________________________________\n FINAL REPORT\n ERCP\n\n HISTORY: 34-year-old woman with biliary colic and abnormal LFTs.\n\n COMPARISON: CT of the abdomen .\n\n ERCP: Seven spot fluoroscopic images were obtained without a radiologist\n present and was subsequently sent for review. The images demonstrate\n cannulation of the common bile duct and contrast injection with a small\n filling defect in the lower one-third of the common bile duct. There are\n cholecystectomy clips present. Per endoscopy report, a balloon sweep was\n performed with sludge extracted. The common bile duct measures approximately 8\n mm.\n\n IMPRESSION: The common bile duct demonstrates small filling defects in the\n lower one-third, with subsequent sludge extracted using a balloon per\n endoscopist report.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-09-05 00:00:00.000", "description": "SMALL BOWEL ONLY (BARIUM)", "row_id": 975357, "text": " 9:31 AM\n SMALL BOWEL ONLY (BARIUM) Clip # \n Reason: please evaluate for small bowel lesions.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with hx autonomic dystonia with LFT abnormalities, and now\n with new RUQ pain.\n REASON FOR THIS EXAMINATION:\n please evaluate for small bowel lesions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old woman with dysautonomia and right upper quadrant\n pain.\n\n TECHNIQUE:\n 80 cc of thin barium was injected through the J-tube and its passage through\n the small bowel was observed under direct fluoroscopic guidance. Barium passed\n freely through the small bowel reaching the colon in less than 20 minutes.\n Small bowel had normal course and contour, no filling defect was noted.\n\n The content of the G-tube was drained. 5 cc of bilious fluid was aspirated. 20\n cc of Conray was injected through the G- tube that reproduced the patient's\n symptoms of severe gastric pain. The injected contrast was then drained and\n this relieved the patient's symptoms. No obstructive lesion was noted within\n the duodenum.\n\n IMPRESSION:\n 1. Normal small bowel study.\n\n 2. Injection of the contrast into the stomach through the G-tube reproduced\n the patient's symptoms.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-08-31 00:00:00.000", "description": "ABD COMPL INCLUDING LAT DECUB", "row_id": 974617, "text": " 10:54 AM\n ABD COMPL INCLUDING LAT DECUB Clip # \n Reason: ? tube placement vs. free air\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with GJ tube replaced two days ago, now with worsening\n abdominal pain.\n REASON FOR THIS EXAMINATION:\n ? tube placement vs. free air\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 34-year-old woman with GJ tube placement two days ago\n with worsening abdominal pain, question tube placement. Assess for free air.\n\n FINDINGS: Three views of the abdomen were obtained and compared to the prior\n examination dated . There is a gastrojejunal feeding catheter in\n place that appears to terminate within the expected region of the jejunum.\n There is an electronic device again noted overlying the right hemipelvis.\n Surgical clips are seen within the right upper quadrant. No free air is seen.\n No evidence of an obstruction. The bowel gas pattern is grossly unremarkable.\n Stool is noted throughout the colon. The lung bases are clear.\n\n IMPRESSION:\n 1. No gross free air, consider CT if clinically warranted for further\n evaluation for, it is a more sensitive examination.\n 2. GJ tube in a grossly satisfactory position. Again, a CT is a more\n sensitive examination for the evaluation of the tip location.\n\n" }, { "category": "Radiology", "chartdate": "2127-08-29 00:00:00.000", "description": "PERC PLCMT GASTROMY TUBE", "row_id": 974393, "text": " 11:35 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Pt has a GJ tube that pulled out this morning. please replac\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with gastroparesis, autonomic dystonia who presents with\n epigastric pain and high ALT/AST that have now resolved.\n REASON FOR THIS EXAMINATION:\n Pt has a GJ tube that pulled out this morning. please replace. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: 34-year-old female with gastroparesis. Previous G-J\n tube pulled out this morning.\n\n RADIOLOGISTS: Dr. and Dr. performed the procedure. Dr.\n , the attending radiologist, was present supervising throughout.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the patient. The patient was placed supine on the angiographic\n table. Pre-procedure timeout was performed. Abdomen was prepped and draped\n in standard sterile fashion. The skin tract was anesthetized with lidocaine\n jelly. Under fluoroscopic guidance, 0.035 Glidewire was advanced through the\n tract into the stomach. A 16 French peel-away sheath was advanced over the\n wire. The internal dilator was removed. A Kumpe catheter was advanced over\n the wire into a jejunal loop. The Glidewire was removed and exchanged by\n another wire. The Kumpe catheter was removed. A 16 French peel-away sheath\n was removed. A 16 French MIC G-J tube was inserted and advanced into the\n jejunum. The wire was removed and the position of the tip of the G-J tube was\n confirmed with injection of air and small amount of contrast material. The\n catheter was flushed and secured to the skin with a 0 Prolene sutures. The\n patient tolerated the procedure well. There were no immediate complications.\n Moderate sedation was not necessary.\n\n IMPRESSION: Successful placement of a 16 French MIC G-J tube, with the tip in\n the proximal jejunum.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-08-25 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 973844, "text": " 6:10 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: Please do CTA of the LIVER to r/o portal thrombosis. assess\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with autonomic dystomia, areflexive bladder, gastroparesis\n presents with transaminitis in the 1000's.\n REASON FOR THIS EXAMINATION:\n Please do CTA of the LIVER to r/o portal thrombosis. assess hepatic\n lvasculature and biliary system\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old female with autonomic dystonia and areflexic bladder,\n presenting with transaminitis. Please assess for portal vein thrombosis.\n\n COMPARISONS: and .\n\n TECHNIQUE: MDCT axial images through the abdomen were obtained without\n contrast. Following the administration of 200 cc of IV Optiray contrast,\n multiphasic images through the liver and pelvis were obtained with multiplanar\n reformats.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: The lung bases are clear. The\n patient is status post cholecystectomy. A J-tube courses to the jejunum. The\n liver, adrenal glands, kidneys, and pancreas are unremarkable. Both ureters\n course into a neobladder within the lower right pelvis which is unchanged and\n appears intact. A focus of air is seen within the common bile duct. There is\n no free fluid or free air in the abdomen.\n\n CT PELVIS WITH IV CONTRAST: Again seen is a complex tubular structure within\n the right adnexa consistent with hydrosalpinx. A previously seen 3.6 cm right\n adnexal structure has resolved. There is a small amount of fluid in the\n vaginal vault. There is a right sacral nerve stimulator.\n\n Osseous structures demonstrate no suspicious lytic or sclerotic foci.\n\n CTA ABDOMEN: The aorta, celiac axis, SMA, and are widely patent. Both\n renal arteries are patent. The portal vein is patent without evidence of\n thrombosis.\n\n IMPRESSION:\n\n 1. No portal vein thrombosis.\n\n 2. Splenomegaly.\n\n 3. Right complex adnexal structure likely representing hydrosalpinx.\n\n\n\n (Over)\n\n 6:10 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: Please do CTA of the LIVER to r/o portal thrombosis. assess\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2127-08-25 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 973823, "text": " 2:59 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: SPLEENOMEGALY\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with RUQ and epigastric abd pain; labs showed ALT and AST in\n thousands. S/P CCY. h/o gastroparesis w/ GJ tube. s/p urostomy\n REASON FOR THIS EXAMINATION:\n need US with doppler\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old female with elevated AST and abdominal pain.\n\n COMPARISON: Abdominal ultrasound, .\n\n DOPPLER ULTRASOUND: There is normal cardiac variation in the hepatic veins\n and IVC. The main left and right portal veins are patent with hepatopetal\n flow. Waveforms of the main right and left hepatic arteries demonstrate good\n upstroke and resistive indices ranging from 0.6-0.8 cm/sec.\n\n IMPRESSION: Normal Doppler ultrasound.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-08-24 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 973729, "text": " 11:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: elevated ALT, AST, AlkPhos, assess for retained stone, enlar\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with RUQ and epigastric abd pain; labs showed ALT and AST in\n thousands. S/P CCY. h/o gastroparesis w/ GJ tube. s/p urostomy\n REASON FOR THIS EXAMINATION:\n elevated ALT, AST, AlkPhos, assess for retained stone, enlarged CBD\n ______________________________________________________________________________\n WET READ: AHPb SUN 11:45 PM\n normal cbd (5mm), mild intrahepatic ductal dilation, also can be seen post\n ccy. i did not appreciate fatty liver. no shadowing stones identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant pain with elevated LFTs and status post\n cholecystectomy.\n\n FINDINGS: Right upper quadrant ultrasound is compared to .\n The gallbladder is surgically absent. There is mild intrahepatic biliary\n ductal dilation. The common bile duct measures 5 mm. No shadowing stones are\n identified. There is mild hydronephrosis of the right kidney that is\n unchanged from . The echotexture of the liver is normal.\n\n IMPRESSION:\n 1. Normal-appearing common bile duct, without shadowing stones.\n 2. Unchanged mild right hydronephrosis.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2127-09-01 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 974831, "text": " 5:11 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: PAIN PLEASE ASSESS FOR GALL STONES IN DUCTS\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with RUQ and epigastric abd pain; labs showed ALT and AST\n in thousands, now resolving. S/P CCY. h/o gastroparesis w/ GJ tube. s/p\n urostomy. now c/o of RUP again for past day\n REASON FOR THIS EXAMINATION:\n please assess for gall stones in ducts\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old female with elevated transaminases, upper abdominal\n pain, status post cholecystectomy with GJ tube previously placed for\n gastroparesis, concern for choledocholithiasis.\n\n COMPARISON: CT of the abdomen and pelvis, .\n\n RIGHT UPPER QUADRANT ULTRASOUND: No focal or textural hepatic abnormalities\n are identified. There is no biliary ductal dilatation. The common duct\n measures 3 mm in normal maximal caliber. The patient is status post\n cholecystectomy. There is no ascites in the upper abdomen. No common duct\n stones are seen. Feeding tube seen within the duodenum.\n\n IMPRESSION: No biliary dilatation or evidence of common duct stones. Status\n post cholecystectomy.\n\n" }, { "category": "Radiology", "chartdate": "2127-08-28 00:00:00.000", "description": "RENAL U.S.", "row_id": 974288, "text": " 5:31 PM\n RENAL U.S. Clip # \n Reason: please rule-out perinephric abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with recurrent UTI and diverting ileostomy\n REASON FOR THIS EXAMINATION:\n please rule-out perinephric abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old woman with recurrent UTI and diverting ileostomy.\n Rule out perinephric abscess.\n\n RENAL ULTRASOUND: The right kidney measures 11.4 cm in length. The left\n kidney measures 10.4 cm in length. There is no nephrolithiasis or\n hydronephrosis on either side. No renal masses or perirenal fluid collections\n are seen. The bladder is not seen, consistent with ileal conduit.\n\n IMPRESSION: No evidence of perinephric abscess or hydronephrosis.\n\n" }, { "category": "Nursing/other", "chartdate": "2127-08-26 00:00:00.000", "description": "Report", "row_id": 1646032, "text": "Nursing Progress Note 2200-0700\n*Full code\n\n*Access: R upper chest Hickman\n\n*Allergies: Demerol, Dilaudid, Ciprofloxacin, Bacitracin, Neosporin, Adhesive tape, Latex\n\n**Admit: pt came into hospital the night before last w/ c/o abd pain. Liver US was done in ED and again w/ doppler once on the floor (both negative). In afternoon attempted CT w/ IV contrast, pt becam rigid/stiff and non-responsive. Taken backt o the floor and given Valium, became tachy to 130's, BP 130's (high for this pt), and decreased RR. Gave 2mg IV morphine and benadryl and later 10mg Valium. Body loosened but pt remained \"in a trance or stupor\" per floor nurse. To Micu to monitor. Arrived alert, responsive and able to communicate. Given another dose of Valium (10mg). Slept comfortably most of shift.\n\nNeuro: slept most of shift, easily arousable, no c/o pain just some overall discomfort after being rigid for some time (stated it is typical following those bouts of rigidity and stiffness). Stated she is able to get herself in her wheelchair @ home, though legs typically stay stiff and crossed. Autonomic dystonia typically when hot, cold, or has infection (currently w/ UTI).\n\nCardiac: A-paced w/o ectopy, HR 80-82 w/ x1 episode of tachy to 130 (pacer max, should not exceed 130), pt stated she felt fine during episode, self corrected in 2-3min. SBP 88-138. Hct 28.5, K 3.4 (awaiting Md orders for repletion).\n\nResp: o2sat 96-98 on RA, rr 15-20, LS clear.\n\nGI/GU: G-J tube clamped (does not use for tube feeds any longer since started TPN @ home, does flush and aspirate daily). +BS, no stool this shift, abd soft non-tender. Urine out urostomy site (bag intact) 30-80cc/hr, yellow/clear. FSBG following Q6H since no TPN @ this time, last FS 91. Started on D5 @ 100cc/hr while no TPN. LFT's trending down, rise caused by infectious process.\n\nID: Temp 96.3-96.4, wbc 6.1. Currently on Ceftriaxone for UTI. contact precautions for hx MRSA (blood, urine, G-J tube wound site). Skin intact, hickman site wnl.\n\nPsychosocial: lives w/ husband and has dog that visits in hosp. Has visiting nurse @ home as well.\n\nDispo: cont to monitor MS and resp status, ? return to floor today.\n" }, { "category": "ECG", "chartdate": "2127-08-28 00:00:00.000", "description": "Report", "row_id": 118615, "text": "Baseline artifact. Atrial pacing. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing no significant change.\n\n" }, { "category": "ECG", "chartdate": "2127-08-26 00:00:00.000", "description": "Report", "row_id": 118616, "text": "Atrially paced rhythm with intrinsic A-V conduction. Compared to the previous\ntracing of there are new T wave inversions in leads III, aVF and V3-V5\nand the rhythm is now atrial paced with intrinsic A-V conduction as compared to\nthe previous tracing of . Question anterolateral and apical ischemic\nchanges. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2127-08-26 00:00:00.000", "description": "Report", "row_id": 118617, "text": "A-V sequentially paced rhythm at rapid rate, new as compared to the previous\ntracing of . Followup and clinical correlation are suggested.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2191-02-24 00:00:00.000", "description": "Report", "row_id": 68819, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 215\nBSA (m2): 2.20 m2\nBP (mm Hg): 124/70\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 12:03\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: Lipomatous hypertrophy of the interatrial\nseptum.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Moderately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; basal inferior - akinetic; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is top\nnormal/borderline dilated. Overall left ventricular systolic function is\nmoderately depressed. Resting regional wall motion abnormalities include\ninferior akinesis/hypokinesis and inferolateral hypokinesis and mild to\nmoderate global hypokinesis. The aortic valve leaflets are mildly thickened.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is a small pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2191-02-21 00:00:00.000", "description": "Report", "row_id": 147358, "text": "Atrial fibrillation with rapid ventricular response.\nSlight nonspecific ST-T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2191-02-20 00:00:00.000", "description": "Report", "row_id": 147389, "text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nConsider left atrial abnormality\nModest nonspecific ST-T wave changes\nSince previous tracing of , ventricular rate increased and further ST-T\nwave changes present\n\n" }, { "category": "ECG", "chartdate": "2191-02-18 00:00:00.000", "description": "Report", "row_id": 147390, "text": "Atrial fibrillation\nLong QTc interval\nLateral ST changes are nonspecific\nRepolarization changes may be partly due to rhythm\nNo change from previous\n\n" }, { "category": "Nursing/other", "chartdate": "2191-02-22 00:00:00.000", "description": "Report", "row_id": 1379750, "text": "MICU NPN 7P-7A\nNEURO: APPEARED CONFUSED ON ARRIVAL, DIFFICULT TO UNDERSTAND WITH DRY MUCOSA. WIFE IN AND PATIENT ORIENTED. PATIENT HAS REMAINED AAOX3. DISORIENTED AND YELLING OUT WHEN AWAKES BUT QUICKLY REORIENTS SELF. C/O ABD PAIN WITH PALPATION BUT DENIED PAIN AT REST REMAINDER OF SHIFT. FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES. SLEPT WELL. NO TREMORS, ON PARKINSON MEDS.\n\nCARDIAC: HR 120'S ON ARRIVAL. SETTLED QUICKLY AND STARTED ON 5MG IV LOPRESSOR QID. HR DOWN TO THE 70'S IN AFIB. OCCASIONAL ECTOPY. BP 124-159/60-104. HCT STABLE @32.\n\nRESP: ON 5L N/C WITH RR 19-30 AND SATS 91-97%. MOUTHBREATHER WHEN ASLEEP. WOULD DESAT AND QUICKLY RECOVER. ?OSA. LS CLEAR WITH DIMINISHED LEFT BASE AND RIGHT BASE COARSE WITH ?FINE CRACKLES. DENIED SOB.\n\nGI/GU: ABD SOFT WITH +BS. SMEAR OF GREEN STOOL. UOP 17-70CC/HR AMBER AND CLEAR. CREAT 1.1.\n\nFEN: RECEIVED 1L FLUID BOLUS. LYTES PER CAREVUE. REMAINS NPO X MEDS.\n\nID: TEMP WAS 104.4 RECTALLY ON ARRIVAL. ?VALIDITY OF DISPOSABLE THERMOMETERS. 2.5HRS LATER TEMP DOWN TO 100.8 WITH JUST COOLING BLANKET ON. DOWN TO 99.8 THIS MORNING. BLOOD CX'S DRAWN. PREVIOUS BLD CX'S GREW GNR IN BOTTLES. CONTINUES ON ZOSYN AND STARTED ON VANCO. WBC IS 6.\n\nSKIN: W/D/I.\n\nACCESS: PIV X3.\n\nSOCIAL/DISPO: FULL CODE. WIFE AND SON INTO VISIT. PATIENT DOING WELL AND ?CAN BE CALLED OUT.\n" }, { "category": "Radiology", "chartdate": "2191-02-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 906180, "text": " 2:39 AM\n PORTABLE ABDOMEN Clip # \n Reason: THIS IS A SECOND REQUEST, ************STAT*****************\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with AF on coumadin, also PD, here with CHF exacerbation now\n with abdominal pain x 3 hr, with epigastric pain and guarding, no rebound. and\n now AF with RVR\n REASON FOR THIS EXAMINATION:\n THIS IS A SECOND REQUEST, ************STAT***********************? megacolon,\n free air\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, , 2:51 a.m.\n\n INDICATION: Abdominal pain and epigastric pain.\n\n There is a nonobstructive bowel gas pattern visualized, with air and stool\n within nondistended colon and air within nondistended loops of small bowel.\n If there is clinical suspicion for free intraperitoneal air, dedicated upright\n or left lateral decubitus view would be recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 906049, "text": " 6:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL.R/O BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with falls\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa FRI 7:32 PM\n No bleed, no mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with fall.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: Head CT dated .\n\n FINDINGS: There is no acute intracranial hemorrhage. No evidence of mass\n effect is seen. Beam hardening artifacts are seen. Bilateral ventricles are\n symmetric and not dilated. Note is made of small amount of soft tissues in\n bilateral ethmoid and maxillary sinuses. The osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. No evidence of\n mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906186, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening CHF, ? PNA\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CHF, AF, new abdominal pain and now new O2 requirement.\n\n REASON FOR THIS EXAMINATION:\n ? worsening CHF, ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST COMPARISON, .\n\n COMPARISON: .\n\n INDICATION: Increased oxygen requirement.\n\n There is stable cardiomegaly, and persistent congestive heart failure with\n interstitial edema. New in the interval are increased opacities in the\n retrocardiac region bilaterally as well as a small left pleural effusion.\n\n IMPRESSION:\n\n 1. Persistent congestive heart failure with interstitial edema.\n\n 2. New retrocardiac opacities, which may relate to dependent edema.\n Aspiration pneumonia should also be considered.\n\n 3. Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2191-02-20 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 906222, "text": " 12:14 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: RUQ PAIN, TACHYCARDIA, R/O PE\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 y/o M new RUQ pain, O2 req, tachycardia\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant pain, hypoxia, tachycardia. Please evaluate\n for pulmonary embolus.\n\n TECHNIQUE: Multidetector CT images were obtained through the chest, first\n without contrast with a low-dose technique, followed by a CT angiogram of the\n chest in the pulmonary arterial phase. Coronal, sagittal, and oblique\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no\n evidence of pulmonary embolus. Calcifications are seen within the aorta. The\n right atrium of the heart is enlarged. There is a small pericardial effusion.\n The airways are patent to the segmental level bilaterally. No filling defects\n are seen within the visualized bronchi. The lung fields show atelectasis\n versus consolidation at the bilateral lung bases. There are large bilateral\n pleural effusions. There are multiple small non-pathologically enlarged lymph\n nodes in the bilateral axillae, and within the prevascular, aortopulmonary\n window, and pretracheal regions of the mediastinum. There is no hilar\n lymphadenopathy. The visualized abdomen shows an unremarkable portion of the\n liver with reflux of contrast down the inferior vena cava suggesting right\n heart failure. The visualized spleen and left kidney is unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative changes and calcification along the anterior longitudinal\n ligament are seen within the visualized thoracic spine.\n\n CT REFORMATS: Coronal and sagittal reformatted images confirm the axial\n findings. Value grade 1.\n\n IMPRESSION:\n 1. No evidence for pulmonary embolus.\n\n 2. Large bilateral pleural effusions with bilateral air space opacities at\n the lung bases representing atelectasis versus consolidation.\n\n 3. Small pericardial effusion.\n\n (Over)\n\n 12:14 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: RUQ PAIN, TACHYCARDIA, R/O PE\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2191-02-20 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 906223, "text": " 12:23 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? dilated duct, ? obstruction\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p cholecystectomy, PD, AF, abdominal pain and now\n elevated LFTs.\n REASON FOR THIS EXAMINATION:\n ? dilated duct, ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cholecystectomy with abdominal pain and elevated\n LFTs.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture and\n architecture. No intrahepatic biliary ductal dilatation is identified. No\n focal liver lesions are seen. The patient is status post cholecystectomy.\n The common bile duct measures 6.7 mm, which is normal. The visualized right\n kidney is normal. There is no ascites.\n\n IMPRESSION: Status post cholecystectomy without evidence for intrahepatic or\n extrahepatic biliary ductal dilatation.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-02-21 00:00:00.000", "description": "ERCP BILIARY ONLY BY GI UNIT", "row_id": 906402, "text": " 8:05 PM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: R/O BIliary source\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with severe abd pain.\n REASON FOR THIS EXAMINATION:\n R/O BIliary source\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with severe abdominal pain.\n\n COMPARISON: Right upper quadrant ultrasound .\n\n ERCP: Nine spot fluoroscopic images were obtained without a radiologist\n present. The common bile duct was cannulated and contrast injected. The\n common hepatic and common bile duct are noted to be dilated and small round\n filling defects are seen of the distal common duct, compatible with\n stones. The cystic duct fills with contrast well without evidence of\n stricture or stone. The pancreatic duct was also cannulated and is of normal\n caliber without evidence of stricture or filling defects. A plastic biliary\n stent was placed in the common bile duct.\n\n" }, { "category": "Radiology", "chartdate": "2191-02-18 00:00:00.000", "description": "L HIP UNILAT MIN 2 VIEWS LEFT", "row_id": 906052, "text": " 7:15 PM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: fracturer\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with fall and pain\n REASON FOR THIS EXAMINATION:\n fracturer\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, pain.\n\n COMPARISON: .\n\n AP PELVIS AND TWO VIEWS OF THE LEFT HIP\n\n There is no evidence of acute fracture. Left hip prosthesis is seen without\n evidence of adjacent lucency. Left hip prosthesis appears in near anatomic\n alignment. Degenerative changes seen within the visualized lumbar spine. SI\n joints and pubic symphysis appear unremarkable.\n\n IMPRESSION: No evidence of acute fracture.\n\n" }, { "category": "Radiology", "chartdate": "2191-02-18 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 906053, "text": " 7:15 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: Eval for infiltrate vs CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with shortnes of breath with exertion and hx of CHF.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate vs CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath with exertion, history of CHF, evaluate for\n infiltrate or CHF.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH\n\n Cardiac size appears enlarged. There is a large azygos vein and evidence of\n increased pulmonary markings. No pleural effusions are seen. No focal\n consolidations are identified.\n\n IMPRESSION: Findings consistent with CHF.\n\n" }, { "category": "Radiology", "chartdate": "2191-02-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 906615, "text": " 9:10 AM\n CHEST (PA & LAT) Clip # \n Reason: ? CHF\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with MMP including CHF, cholangitis s/p ERCP, parkinsons, b/l\n effusions on CT\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral effusions on CT. Evaluate for heart failure.\n\n COMPARISON: .\n\n CHEST PA AND LATERAL: Mild cardiomegaly is present. There is improving\n pulmonary edema. There is interval decrease in the size of pleural effusion.\n\n IMPRESSION: Improving mild pulmonary edema and small bilateral effusions.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2195-03-25 00:00:00.000", "description": "Report", "row_id": 1553824, "text": "TSICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SLEEPY WITH MED..BUT NO DROP IN BP...BUT POOR\n PAIN RELIEF. MORPHINE INCREASED TO 4MG IV\n Q2 WITH GOOD RELIEF, AND STABLE BP.\n OX3. COLLAR CLEARED LAST EVE.\n REMAINS ON LOGROLL PENDING BACK CLEARANCE\n BY ORTHO TEAM. (NEUROSURG SIGNED OFF.)\n WEAK IN LOWER EXTREMITIES... SOMEWHAT BASELINE\n PER PT. H/O ARTHRITIS. R KNEE ARTHROSCOPY.\n\nCV: HR AND BP STABLE.\n NO ANTIHTN YET...TAKES ATENOLOL AT HOME.\n\nRESP 2L NC WHEN SLEEPING...? SLEEP APNEA.\n\nRENAL: LABS WNL. GOOD UO.\n\nGI: NPO FOR OR. IV FAMOTIDINE.\n LR AT 125.\n\nHEME: HCT'S STABLE AT 33. NO COAGS TODAY.\n ? LOVENOX WHEN MD APPROVES.\n\nENDO: INSULIN PER SLIDING SCALE.\n\nID: AFEBRILE. NO ANTBXS.\n\nSKIN: BRUISING ALL OVER...ESP. ELBOWS/RIGHT AND LEFT\n FLANK.\n\nSOCIAL: HUSBAND AT BEDSIDE.\n\nA: STABLE AWAITING OR.\nP: OR... TRANSFER TO ORTHO SERVICE.\n" }, { "category": "Nursing/other", "chartdate": "2195-03-25 00:00:00.000", "description": "Report", "row_id": 1553823, "text": "TSICU NSG admit note.\n Pt is 53 y/o ped struck and thrown 20feet, no LOC at the scene GCS 15. Pt admitted to EW and w/u revealed right superior and inferior pubic ramus fx's as well as left sacral fx and left L3 and L5 transverse process fx's.\n PMHX sig for HTN, choley and right knee arthroscopy. Pt w/ intolerance to demerol in the past (made her agitated according to husband), yet besides, Meds at home atenalol and terasin.\n\nPt admitted to TSICU at 2200 for hemodynamic monitoring as well as for frequent hct checks.\n\nCurrent ROS\n\n pt sleepy after MSO4 and ativan in the EW yet easily arousable and oriented times 3. Moving all extremities w/ full strengths, denies any numbness or tingling in LE's. Pt c/o back pain in lower back, says pain is a 9 on scale of yet becomes so sleepy w/ narcatis and ativan, received only 2 additional mgs of MSO4 for the duration of shift and pt slept most od the night.\n\n pt in SR in the 70's , no ectopy, BP 104-134/60-70, easily palpable pulses in LE's, pneumo boots initiated. Hct checks q 4hours over night remained stable. Mag repleted this AM.\n\n pt initially on RA w/ sat 95-99% yet when sleeping sats drifted down to the 89-90 so 2liters NC applied and sats greatly improved at 95-99%. weak nonproductive cough. BS'c clear yet diminished bilaterally.\n\n pt NPO for now, wetting mouth w/ swabs, Abd obese w/ hypoactive bowel sounds.\n\n pt maintaining brisk u/o over night via foley cath,\n\nID - t max 100.- pt not on any abx's at this time. Encouraged to C+DBing.\n\n pt w/ large area of road rash on left flank, very superficial yet weeping serous fluids so covered w; a soft sorb.\n\n pt married w/ one 22 y/o son, lives in and works at the Red Cross in an administative position.\n\nA/ pt stable hemodynamics, potential OR today for sacral srew repair, Hct stable. Con't to monitor closely maintain NPO for now.\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "PELVIS (AP, INLET & OUTLET)", "row_id": 855947, "text": " 6:48 PM\n PELVIS (AP, INLET & OUTLET) Clip # \n Reason: delineation of fx, preop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with inf sup pubic rami fx, sacral fx\n REASON FOR THIS EXAMINATION:\n delineation of fx, preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma.\n\n PELVIS, AP, INLET AND OUTLET VIEWS: There are mildly displaced fractures of\n the left superior and inferior pubic ramus. There is also a nondisplaced\n fracture of the left sacrum as seen on CT. There are transverse process\n fractures at L3 and likely L5. Note is made of a Foley catheter with contrast\n within the bladder.\n\n IMPRESSION: Fractures of the left sacrum and right superior and inferior pubic\n rami. Left- sided transverse process fractures.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 855948, "text": " 6:48 PM\n L-SPINE (AP & LAT); T-SPINE Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pelvic fx, ped v car\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, pedestrian hit by car.\n\n T/L SPINE, FOUR VIEWS: The views of the thoracic spine are limited due to\n patient body habitus. No gross evidence of fracture is seen. There is\n calcification of the anterior longitudinal ligament consistent with DISH.\n There is also a radiopaque density identified between T9/10 which likely\n represents previous vertebroplasty.\n\n The alignment of the lumbar spine is unremarkable, without evidence of\n fracture. Note is made of contrast within the renal collecting systems.\n Fracture of the left sacrum is seen. Fracture of left-sided transverse\n processes seen on CT not well seen on plain films.\n\n IMPRESSION:\n 1) Films of limited diagnostic quality due to patient body habitus of the\n thoracic spine. No definite fracture seen. Evidence of previous\n vertebroplasty.\n 2) No evidence of lumbar fracture or malalignment. Left- sided sacral\n fracture.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 855939, "text": " 5:33 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ped struck\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn TUE 7:21 PM\n No evidence of fracture or abnormal alignment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female pedestrian struck. Evaluate for fracture.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Axial non-contrast helical scanning of the cervical spine was\n performed without intravenous contrast. Sagittal and coronal reconstructions\n were obtained.\n\n FINDINGS: No disk, vertebral, or paraspinal abnormality is seen. There is no\n sign of fracture or abnormal alignment of the component vertebrae. CT is not\n able to provide any intrathecal detail. The visualized outline of the thecal\n sac appears unremarkable.\n\n IMPRESSION: Normal cervical spinal CT.\n\n\n NOTE ADDED AT ATTENDING REVIEW: These images, and this report, became\n available for interpretation on , and were approved at this time.\n Incidentally noted is calcification in the left lobe of the thyroid gland,\n not well characterized due to overlying artifacts.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 855940, "text": " 5:34 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ped struck\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female pedestrian struck.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: MDCT axially acquired images from the lower lungs through the\n pubic symphysis were obtained following the administration of 150 cc of\n intravenous Optiray. Non-ionic contrast was administered for protocol.\n Delayed bladder, cystogram, coronal and sagittal reconstructed images were\n obtained.\n\n CT OF THE ABDOMEN WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: Images through to\n the lung bases reveal minimal bilateral pleural effusions with dependent\n atelectasis. There is a small air filled collection adjacent to the esophagus\n possible representing an esophageal diverticulum vs. paraesophageal hernia.\n The liver parenchyma is normal in appearance without evidence of nodules or\n masses. The patient is S/P cholecystectomy. The pancreas spleen and left\n adrenal gland are unremarkable. Within the right adrenal gland, there is a 3.7\n x 2.7 cm mass measuring 60 Houndsfield units, possibly representing right\n adrenal adenoma. Bilateral kidneys enhance and excrete contrast symmetrically.\n Intra-abdominal loops of large and small bowel are unremarkable. There is a\n left lower abdomen retroperitoneal hematoma adjacent to the left psoas muscle\n and extending into the pelvis. There is no evidence of active contrast\n extravasation. There is no mesenteric, or retroperitoneal lymphadenopathy.\n There is a fat-contining periumbilical hernia.\n\n CT OF THE PELVIS WITHOUT ORAL WITH INTRAVENOUS CONTRAST: There is expansion\n of the left obturator muscle consistent with hematoma. Additionally, within\n the right lower pelvis, there is high density fluid suggesting hematoma, with\n a small focus of high density anteriorly, adjacent to the pubic ramus. This\n focus persists on delayed imaging, and appears unchanged. Delayed and\n cystogram images reveal normal appearance of the bladder. A Foley catheter is\n seen within the urethra. The uterus, sigmoid, rectum, are unremarkable. A\n contusion is noted in the left buttocks.\n\n BONE WINDOWS: Multiple fractures are identified within the pelvis. There are\n comminuted fractures of the right ischium and the right superior pubic ramus,\n adjacent to the pubic symphysis. Additionally, there is a left sacral alar\n comminuted fracture. A simple fracture is also seen of the left L3 transverse\n process. Diffuse degenerative changes are seen along the remaining thoracic\n and lumbar spine.\n (Over)\n\n 5:34 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Coronal and sagittal reconstructions were necessary to better delineate the\n anatomy and pathology.\n\n IMPRESSION: 1) Left lower abdomen hematoma adjacent to left psoas abscess,\n extending into the upper pelvis. No evidence of active contrast\n extravasation. Additionally, left obturator, and right anterior pelvic\n hematoma. A small high density focus within the right anterior pelvic\n hematoma possibly represents a bony fragment from the adjacent pubic ramus\n fracture, however this focus could also represent active contrast\n extravasation. It is less likely as the focus appears unchanged on delayed\n imaging.\n 2) Multiple comminuted fractures within the pelvis including the right\n ischium, right pubic ramus, left sacral ala and left transverse process of L3.\n 3) No evidence of ureteral, or urethral injury. No evidence of bladder\n injury.\n 4) 3.7 x 2.7 cm mass within right adrenal. Possibly representing adrenal\n adenoma. Follow up scanning should include a noncontrast sequence for further\n evaluation.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 5:34 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2195-03-26 00:00:00.000", "description": "O PELVIS WITH JUDET VIEWS IN O.R.", "row_id": 856175, "text": " 2:16 PM\n PELVIS WITH JUDET VIEWS IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: PELVIC FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pelvic fracture fixation.\n\n Four AP and 1 lateral view of the pelvis obtained in O.R. during placement of\n 2 cannulated screws across the left SI joint. Bone detail suboptimally\n assessed.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 855937, "text": " 5:30 PM\n TRAUMA #2 (AP CXR & PELVIS PORT); -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: fx, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman ped struck by car\n REASON FOR THIS EXAMINATION:\n fx, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pedestrian struck by car, trauma.\n\n TRAUMA, AP CHEST X-RAY AND PELVIS: The films are slightly limited due to\n the underlying trauma board and the patient's body habitus. The aortic knob\n appears sharp and the mediastinum is likely within normal limits allowing for\n technique. There is no pneumothorax and no pleural effusions.\n\n The hips and SI joints are unremarkable. There are nondisplaced fractures of\n the right superior and inferior pubic rami. No other fractures are identified\n on these limited views.\n\n IMPRESSION: Nondisplaced fractures of the right inferior and superior pubic\n rami. Further evaluation with CT is recommended and is being performed.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 855938, "text": " 5:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 53-year-old female with trauma.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n There is no evidence of acute intracranial hemorrhage, mass effect, or shift\n of normally midline structures. There is no major vascular territorial\n infarction. The density values of the brain parenchyma are within normal\n limits. The -white matter differentiation is preserved throughout.\n Surrounding soft tissue and osseous structures reveal a fracture of the left\n nasal bone. A calcified polyp is identified within the left maxillary sinus.\n\n IMPRESSION: No evidence of intracranial hemorrhage. Fracture of left nasal\n bone.\n\n A wet read was entered into the ED dashboard at 7:15 p.m. on .\n\n NOTE ADDED AT ATTENDING REVIEW: These images and this report became available\n for review on and were approved at this time.\n\n" }, { "category": "Radiology", "chartdate": "2195-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 855979, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o contusion, ptx\n Admitting Diagnosis: PEDISTRIAN STUCK;INFERIOR RAMUS PELVIC FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with low sao2 after trauma\n REASON FOR THIS EXAMINATION:\n r/o contusion, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low O2 sat after trauma.\n\n COMPARISON: None.\n\n FINDINGS: Lung volumes are low. The heart is enlarged. Pulmonary\n vasculature appears prominent. Additionally, there is increased density\n within the left lung, raising the question of aspiration. PA and lateral exam\n recommended for confirmation.\n\n IMPRESSION: Low lung volumes. CHF. Possible left-sided aspiration.\n Confirmation with dedicated PA and lateral exam recommended.\n\n" }, { "category": "ECG", "chartdate": "2195-03-25 00:00:00.000", "description": "Report", "row_id": 192709, "text": "Sinus rhythm. Left atrial abnormality. Prior anteroseptal myocardial\ninfarction. Non-specific ST-T wave abnormalities in leads I, aVL and V5-V6. No\nprevious tracing available for comparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2168-08-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1019664, "text": " 11:54 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for abdominal mass compressing upper GI tract (g\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with Upper GI bleed, PUD with recent EGD with concern for\n external compression on the duodenum\n REASON FOR THIS EXAMINATION:\n please eval for abdominal mass compressing upper GI tract (gastrum/duodenum)\n CONTRAINDICATIONS for IV CONTRAST:\n CKD\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc FRI 11:24 PM\n Marked wall thickening and inflammatory change of the second portion of the\n duodenum, with an ulcer crater located extremely close to the GDA. If ongoing\n bleeding is seen from the ulcer, consider communication with the GDA. No\n pseudoaneurysm currently visualized. No focal pancreatic mass.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old woman with recent EGD for upper GI bleed, with\n diagnosis of peptic ulcer disease, and concern for external compression of the\n duodenum.\n\n COMPARISON: EGD report from .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis following administration of oral and intravenous contrast material.\n Multiplanar reformatted images were also obtained.\n\n CT ABDOMEN: At the lung bases, there are small bilateral pleural effusions\n with associated atelectasis. No airspace consolidation is identified. A\n poorly defined 4-mm ground-glass nodule is present within the right lower\n lobe, incompletely visualized.\n\n The heart size is normal, and a dual-lead pacemaker terminates in the right\n atrium and right ventricle.\n\n Within the liver, mild intrahepatic ductal dilatation is present. A focal\n enhancing lesion is present in segment VII, which is incompletely imaged. The\n CBD measures up to 8 mm. Within the head of the pancreas, the pancreatic duct\n measures up to 5 mm.\n\n Oral contrast material fills the stomach, and passes freely through the\n duodenum. However, the second portion of the duodenum demonstrates marked wall\n thickening and surrounding inflammatory change. Along the medial wall, an\n ulcer crater fills with oral contrast and air, and extends medially to abut\n the pancreatic head. The ulcer crater is extremely close to the gastroduodenal\n artery, which arises from a replaced right hepatic artery. There is no\n evidence of pseudoaneurysm.\n\n The pancreatic head and uncinate process appear normal without mass that could\n cause extrinsic compression of the duodenum.\n (Over)\n\n 11:54 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for abdominal mass compressing upper GI tract (g\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The gallbladder, kidneys, adrenal glands, spleen, and intra-abdominal loops of\n small and large bowel are unremarkable. There is no free air or free fluid in\n the abdomen. No mesenteric lymph nodes meet CT criteria for pathologic\n enlargement.\n\n CT PELVIS: The rectum, sigmoid colon, urinary bladder, uterus and left adnexa\n are unremarkable. The right adnexa demonstrates a 3.2 x 2.1 x 2 cm cyst.\n Intrapelvic loops of bowel are unremarkable. There is no free fluid in the\n pelvis. No pelvic nodes meet CT criteria for pathologic enlargement.\n\n OSSEOUS STRUCTURES: Mild degenerative changes are noted in the thoracic and\n lumbar spine. No lytic or sclerotic bony lesions are identified. No soft\n tissue abnormalities are identified.\n\n IMPRESSION:\n\n 1. Marked wall thickening of the 2nd portion of the duodenum, with an ulcer\n crater located extremely close to the GDA. If there is ongoing bleeding from\n the ulcer, consider communication with GDA. However, no pseudoaneurysm is\n currently visualized. No focal pancreatic mass is identified.\n\n 2. Small bilateral pleural effusions.\n\n 3. Right adnexal cyst measuring up to 3.2 cm. Further evaluation can be\n obtained with pelvic ultrasound once clinically stable.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2168-08-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1019665, "text": ", MED FA7A 11:54 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for abdominal mass compressing upper GI tract (g\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with Upper GI bleed, PUD with recent EGD with concern for\n external compression on the duodenum\n REASON FOR THIS EXAMINATION:\n please eval for abdominal mass compressing upper GI tract (gastrum/duodenum)\n CONTRAINDICATIONS for IV CONTRAST:\n CKD\n ______________________________________________________________________________\n PFI REPORT\n Marked wall thickening and inflammatory change of the second portion of the\n duodenum, with an ulcer crater located extremely close to the GDA. If ongoing\n bleeding is seen from the ulcer, consider communication with the GDA. No\n pseudoaneurysm currently visualized. No focal pancreatic mass.\n\n" }, { "category": "Radiology", "chartdate": "2168-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1019200, "text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infection\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with low grade fever,\n REASON FOR THIS EXAMINATION:\n eval for infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Low-grade fever.\n\n FINDINGS: The left costophrenic angle has been cropped from this image.\n Cardiac silhouette is within normal limits and there is no evidence of\n vascular congestion, pleural effusion, or acute pneumonia. Dual-channel\n cardiac pacemaker device is in place. No evidence of pneumonia.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-08-06 00:00:00.000", "description": "Report", "row_id": 1638438, "text": "MICU 7 RN NOTE 2200-0700\n\nEVENTS: Pt w/ H/O GI bleed initially admitted to MICU 7 on w/ Hct 35 but overnight lost 10 points received blood product and fluids. EGD done ulcer in duodenum cauterized and tx to floor on . In the floor CT w/ contrast was done yesterday and @ night around 2200 she c/o diziness and while walking to toilet she almost dropped herself down but before falling down to ground supported by RN and brought to bed. Then she passed bloody stool Hypotensive to 85/50 received 150cc NS bp picked upto 110/60. Hct dropped from 29-19 1 unit PRBC's started and tx MICU 7 for further management.\n\nALLERGIES: ATROVASTATIN, FENOFIBRATE, SULPHA.\n\nEVENTS: Received one unit PRBC's Hct bumped from 19 to 27.\n\nNEURO: Pt is alert and oriented x3, Moves all four extremities. Denies pain. Very forgetful needs frequent reorientation.\n\nCV: HR in 70's NSR, No ectopy. SBP 105-120. Received 1 unit PRBC's S/P Hct 27. Access PIV x2.\n\nRESP: LS clear, Sats >98% on room air. No issues.\n\nGI/GU: Abd soft, NPO for EGD in AM. No BM after comming to ICU. No N/V. Voids on bedpan.\n\nSOCIAL: Full code. MD called pt husband and updated.\n\nID: 98.2. Abx ciprofloxacillin.\n\nPLAN: EGD in AM, Check Hct q4 and tranfuse as required.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-06 00:00:00.000", "description": "Report", "row_id": 1638439, "text": "NPN 7a-7p\n\n pt. had EGD first thing this am, found no active bleeding, old cauterized ulcers and probable source of bleeding which would need angiography or surgery for repair. Pt. and family aware. Transfused w/ 1u PRBC for HCT <30 (goal 30). Will draw pm labs and lytes (repleted throughout the day- slowly d/t IVs causing pain for pt.). Pt. remains NPO, may need to start IVF tonight.\n\nReview of Systems-\n\nNeuro- forgetful but intact. Rec'd 100mcg of Fentanyl and 2mg of Versed for procedure. In addition, pt. c/o of headache and was given Elavil and 1tab of Tylenol #3 with good affect.\n\nResp- no issues\n\nCV- VSS. Pacer. Pneumoboots placed on. Awaiting repeat labs. Repleted Ca+ and Mg+ IV.\n\nGI- ABD soft/ tender/ slightly distended, + flatus. Remains NPO. Awaiting angiography/ surigical repair of artery causing bleed. Will continue to follow q4 hour HCT overnoc.\n\nGU- Voiding in bedpan well.\n\nID- Cipro d/c'd (e.coli in urine previously). Afebrile.\n\nAccess- Replaced #22 w/ #18 in the setting of it leaking. Pt. now has 2 18 gauge. IV nurse assesed pt. and thought that would only be able to place 1 more 20 guage if needed.\n\n Husband and 2 at bedside and updated by myself and resident.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-07 00:00:00.000", "description": "Report", "row_id": 1638440, "text": "Nursing Porogress Note:\nPt re-admitted to MICU from floor; awhile ambulating, felt dizzy, and fell to floor (lowered by floor nurse), BP drop to 80's, fluid bolus given passed large melanotic stool, transferred to MICU; has rec'd total of 3 units since admission; EGD shows non-bleeding ulcer in diverticulum, GI recs to consult angio\n\nFULL CODE\n\nALLERGIES: SULFA, FENOFIBRATE, LIPITOR\n\nNEURO: no deficits, pt A+Ox3, c/o pain at IV sites with fast infusions/flushing; also c/o HA relieved with standing elavil; moves all extreities, follows commands, pupils 3mm and brisk bilaterally\n\nCV: HR 70's, V/AV paced, no ectopy; q4h HCT, 31.6 -> 32.1 -> 30.2, am CBC and lytes pending; BP stable, 158-114/38/64, MAP >60; +PP to palpation\n\nRESP: LSCTA bilaterally; pt on RA satting 97-99%; RR regular 20-11, no dyspnea/SOB\n\nGI: +BS x4, abd soft non-tender to palpation, non-distended; c/o stomache aching; no stools this shift; pt NPO except meds and water; GIB issues and GI symptoms have been present for a few months and pt reporting poor appetite and weight loss; cont on IV protonix \n\nGU: pt voiding in bedpan qs clear yellow urine\n\nSKIN: small breakdown over coccyx, duoderm applied\n\nACCESS: 2x 18G PIV WNL\n\nPOC: follow HCT q4, transfuse for HCT <30; IV PPI; folllow lytes and replete prn; angio consult\n" }, { "category": "Nursing/other", "chartdate": "2168-08-07 00:00:00.000", "description": "Report", "row_id": 1638441, "text": "MICU7 RN note 0700-1900\n\nEvents: Hct stable @31 x3 no further bleed, Diet adv to clear liquids tol well. GI consult/ following. called out to floor waiting bed assignment.\n\nrefer to transfer note and flow sheet for further data.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-02 00:00:00.000", "description": "Report", "row_id": 1638434, "text": "Micu Nursing Progress Notes\n61 YO female admitted from an OSH with GI bleed.\n\nAllergies: sulfa; atorvastatin; fenofibrate.\n\nPast medical Hx; cardiac arrest C/B encephalopathy, perment pacermaker, CHB; cardiomyopathy, HTN; CAD.\n\nPt has had 3 admissions in 8 days for anemia related to GI bleed. She was D/C'ed , during that admission EDG showed non-bleeding gastric ulcer, duodenal diverticulum and esophageal stricture. She was transfused to HCT of 30 then D/C'ed for capsule enteroscopy. On she felt weak and dizzy. She was found to have a HCT of 15 and she was admitted to their ICU. She was transfused with 3u of RBC's, her stools were initially brown but turned melanotic. She was transfused with 4 more units over the next several days. The EDG was inconclusive so she was transported to for further W/U.\n\nNeuro: SHe is awake and alert,pleasant and cooperative. She was able to transfer from the stretcher to the bed by walking, she was steady on her feet. She did C/O being dizzy during the transfer.\n\nCardiac: initially her B/P wasd 137/63, HR 94 Vpaced, W/I 120 minutes she started to C/O being cold and clamy and her B/P had falled to 101/62, HR 103. She was given 500cc NS IVB and her B/P increased to 131/60, HR 89.\n\nResp: RR 13-16, O2 sats on room air 97-99%. Breath sounds are clear.\n\nGI: Abd soft and non tender, (+) bowel sounds.\n\nGU: She voided 100cc of clear yellow urine on admission , UA sent.\n\nID: temp 99.9, WBC 12.2.\n\nSkin: She has a small reddened area on her coccyx. The dueoderm applied by OSH was removed and not replied. She will be encouraged to stay off her back. She also C/O left flank pain due to her fall at home. CXR at the OSH showed no rib fracture.\n\nSocial: Her husband and daughter came in from . Asking many appropriate, spoke to the RN and resident about plan of care.\n\nPlan: monitor HCT closely overnight, monitor B/P and HR, also I&O, check with GI team for their plan of care-probable EDG tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-03 00:00:00.000", "description": "Report", "row_id": 1638435, "text": "MICU 7 RN REPORT 1900-0700\n\nEVENTS: FLUID BOLUS, BLOOD TRANSFUSION,\n\nNEURO: Pt is alert and oriented x3, . Moving all four extremities. C/O severe migrane head ache received tylenol no.3 w/ effect. Also received her regular home med trazadone 150mg slept fairly.\n\nCV: HR 90 V paced, No ectopics. Hypotensive to 82/45 received ringers lactate 1500cc. Hct @ 2300 dropped from 35 to 29 transfused 2 units PRBC's AM labs pending. Access PIV x2.\n\nRESP: LS clear sating 99% on room air. No issues.\n\nGI/GU: Abd soft, BS positive. No BM. Has lt flank pain related to previous fall but no skin color changes or inflammatory response noted. Sips of water given w/ meds but kept NPO after midnight for EGD in am. Voiding clear yellow urine.\n\nSKIN: Coccyx red duoderm intact.\n\nSOCIAL: Full code. Family stayed @ the bedside untill 2100 updated by MD.\n\nPLAN: EGD in AM. Check Hct Q4H and transfuse if needed. ? CT if EGD is normal.\n" }, { "category": "Nursing/other", "chartdate": "2168-08-06 00:00:00.000", "description": "Report", "row_id": 1638436, "text": "Addendum:\n\n ERROR. This is another pt note. Please read the note below for pt sheaf notes.\n\n" }, { "category": "Nursing/other", "chartdate": "2168-08-06 00:00:00.000", "description": "Report", "row_id": 1638437, "text": "MICU 7 RN REPORT 1900-0700\n\nNO SIGNIFICANT EVENTS OVERNIGHT.\n\nNEURO: Pt is alert on vent. Mouthing words and following commands. Moves all four extremities. Denies pain.\n\nCV: HR 64-80 NSR no ectopics. SBP 100-125. Heparin GTT 500units/hr PTT therapeutic. AM labs pending. Access LIJ TL.\n\nRESP: LS coarse. On vent CPAP 40%/ no vent changes overnight. Very comfortable on the vent. Suctioned for blood tinged thick sec, Has lot of oral sec needs freq gentle suctioning. Sats >95%.\n\nGI/GU: Abd soft, BS positive. Tube feeding nutrene w/ beneprotein 10cc/hr. Has oral ulcers mouth care attempted gently. Mushroom cath draining brown loose stool. Foley draining yellow clear urine. UO 5-30cc/hr.\n\nSKIN: Impaired refer carevue. Dressing changed.\n\nSOCIAL: Full code.\n\nPLAN: Cont routine ICU care. Wean vent as she tolerates.\n" }, { "category": "ECG", "chartdate": "2168-08-03 00:00:00.000", "description": "Report", "row_id": 221084, "text": "Sinus rhythm. Atrial sensed and ventricular paced rhythm with capture.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2120-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 794835, "text": " 3:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, check line position\n Admitting Diagnosis: RIGHT HEEL ULCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman s/p RIJ CVL\n REASON FOR THIS EXAMINATION:\n r/o PTX, check line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman S/P right IJ central venous line.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison . A right IJ line is\n present with its tip in the lower SVC/cavoatrial junction. An endotracheal\n tube is present in satisfactory position. Multiple wires overlie the patient.\n The patient is S/P median sternotomy. The heart size is within normal\n limits. There is elevation of the left hemidiaphragm and left patchy\n retrocardiac opacity is present. The lungs are otherwise clear. Osseous\n structures are grossly unremarkable.\n\n IMPRESSION: 1) Right IJ central venous line with tip in the region of the\n cavoatrial junction. No pneumothorax.\n\n 2) Left retrocardiac opacity and elevation of the hemidiaphragm most likely\n represents atelectasis; however aspiration or pneumonia cannot entirely be\n excluded in this region.\n\n" }, { "category": "ECG", "chartdate": "2120-07-25 00:00:00.000", "description": "Report", "row_id": 142838, "text": "Sinus bradycardia. Borderline short P-R interval - may be within normal limits.\nModest diffuse low amplitude T waves. Since the previous tracing of \nsinus bradycardia is present.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2133-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990602, "text": " 6:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with copd emphysemia, in icu for acute hypoxia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD in the ICU for acute hypoxia. Assess for change.\n\n COMPARISON: and .\n\n SUPINE AP CHEST: There are improved lung volumes compared to yesterday, with\n improved aeration of the lung bases bilaterally. Retrocardiac atelectasis\n persists, however. Moderately severe emphysematous changes are apparent, and\n increased interstitial markings in the lung bases compared to \n indicate edema superimposed on fibrotic change. A small amount of fluid is\n seen in the right minor fissure. Changes related to the gastric pull-up are\n again noted.\n\n IMPRESSION: Moderate pulmonary edema superimposed on chronic obstructive\n disease. Improved lung volumes compared to yesterday.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-01-12 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 991294, "text": " 10:10 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evaluate for aspiration\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with esophageal cancer and 2 episodes of aspiration\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal cancer, s/p resection, now with history of aspiration\n and recurrent pneumonias. Question penetration and aspiration from swallowing\n source.\n\n VIDEO FLUOROSCOPIC OROPHARYNGEAL SWALLOWING EVALUATION: The oral phase was\n normal. The pharyngeal phase was notable for delayed initiation of\n swallowing; however, there is normal hyoid excursion and laryngeal elevation\n after initiation of the swallow. No penetration or aspiration was seen.\n Limited fluoroscopic images of the thorax show the gastric pull through. Of\n note, the patient complained of fullness after swallowing, however, no mass\n lesion was identified.\n\n Limited fluoroscopic images also demonstrate degenerative changes in the\n cervical spine.\n\n IMPRESSION: No evidence of penetration or aspiration on swallowing. For full\n details, please see the report by speech and services\n of the same day.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-01-04 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 990189, "text": " 10:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for PE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with esophageal ca s/p esophagogastrectomy, bilateral pleural\n effusions, L>R, p/w SOB, hypoxic, tachpnea.\n REASON FOR THIS EXAMINATION:\n Evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd SUN 1:38 PM\n 1. Increased pericardial effusion since . 2. Increased bilateral basilar\n atelectasis. 3. New small left effusion. 4. Increased mediastinal , liekly\n due to CHF. 5. No PE.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with esophageal cancer, status post distal\n gastrectomy, bilateral pleural effusions, left greater than right, presenting\n with shortness of breath, hypoxic, tachypnea. Evaluate for PE.\n\n TECHNIQUE: CTA of the chest without and with contrast.\n\n COMPARISONS: (PET CT) and (chest CT).\n\n CTA CHEST: There is normal filling of the pulmonary arterial vasculature\n without evidence of pulmonary embolism. There is interval increase in the\n size of the pericardial effusion, now small to moderate. Subtle pericardial\n enhancement is noted. The patient is status post gastric pull-up for\n esophageal cancer. There is mediastinal lymphadenopathy, which appears to have\n increased in the short interval since . This is concerning\n for either infection or may be caused by CHF. Again noted is severe\n centrilobular emphysema bilaterally with predominance in the upper lobes.\n There is stable left lower lobe atelectasis and effusion. There is a new\n small right-sided pleural effusion with associated mild compressive\n atelectasis. In addition, there is worsening of bilateral basilar\n atelectasis. No axillary lymphadenopathy.\n\n Non-contrast images through the upper abdomen do not demonstrate acute\n pathology. The patient is status post cholecystectomy.\n\n BONE WINDOWS: No evidence of suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Increased pericardial effusion, now small to moderate. Note is also made\n of subtle pericardial enhancement - in conjunction with the FDG avidity of the\n pericard on the recent PET-CT this raises the possibility of pericarditis. D/w\n Dr. on .\n 2. New small right-sided pleural effusion.\n 3. Increased bilateral basilar atelectasis.\n 4. Increased mediastinal lymphadenopathy in the short interval since , . While the lymphadenopathy per se is concerning for metastatic\n (Over)\n\n 10:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for PE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n disease, the rapid interval change is more likely due to congestive heart\n failure or may due to infection.\n 6. No evidence of PE.\n\n Pertinent findings were displayed on the ED dashboard and reviewed with the ED\n staff.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990779, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary vascular congestion, heart size\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with pericardial effusion, esophageal ca\n REASON FOR THIS EXAMINATION:\n ? pulmonary vascular congestion, heart size\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Heart size in a patient with pericardial effusion and\n esophageal cancer.\n\n Portable AP chest radiograph compared to .\n\n No significant change in the heart size is demonstrated. There is also no\n change in the mediastinal contour including the appearance of the\n neoesophagus. Compared to yesterday, there is slight improvement in the basal\n opacities suggesting partial resolution of pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2133-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990440, "text": " 6:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Reason for desaturation.\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with COPD Exacerbation now with acute desaturation.\n REASON FOR THIS EXAMINATION:\n Reason for desaturation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD with exacerbation.\n\n FINDINGS: Comparison study of , there is little overall change. In this\n patient with esophageal cancer and a gastric pull-through, there is\n enlargement of the cardiac silhouette with hyperexpansion of the lungs and\n diffuse prominence of interstitial markings consistent with chronic pulmonary\n disease, increased pulmonary venous pressure, or both. The right costophrenic\n angle is more blunted than on the previous study, suggesting pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990178, "text": " 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, worsening effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with chest pain, history of esophageal cancer\n REASON FOR THIS EXAMINATION:\n eval for CHF, worsening effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 69-year-old male with chest pain, history of esophageal\n cancer. Evaluate for CHF, worsening effusion.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH: Post-surgical changes related to a gastric pull-through\n is identified. There is severe emphysema. Small bilateral pleural effusions\n are present. Cardiomediastinal contours are stable. No pneumothorax is\n appreciated. Atelectasis and scarring persists at the lung bases.\n\n IMPRESSION: Persistent bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2133-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990909, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess infiltrates\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with step PNA, s/p esophagectomy\n REASON FOR THIS EXAMINATION:\n please assess infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n S/P pneumonia. S/P esophagectomy.\n\n Comparison is made to prior study performed a day earlier.\n\n Left lower lobe retrocardiac atelectasis is persistent. There has been\n interval worsening of moderate fluid overload with increase in small bilateral\n pleural effusions greater on the right side. There are lower lung volumes.\n Cardiac silhouette is mildly enlarged.\n\n jr\n\n DR. \n" }, { "category": "Echo", "chartdate": "2133-01-07 00:00:00.000", "description": "Report", "row_id": 65886, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion\nHeight: (in) 6\nWeight (lb): 124\nBSA (m2): 0.29 m2\nBP (mm Hg): 105/70\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 15:36\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\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\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%) Right ventricular chamber size and free wall\nmotion are normal. There is a small posterolateral pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the pericardial effusion is smaller.\n\n\n" }, { "category": "Echo", "chartdate": "2133-01-09 00:00:00.000", "description": "Report", "row_id": 65885, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion - follow up .\nHeight: (in) 64\nWeight (lb): 124\nBSA (m2): 1.60 m2\nBP (mm Hg): 110/60\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 09:40\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no 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: Normal IVC diameter (<2.1cm) with 35-50%\ndecrease during respiration (estimated RAP (0-10mmHg).\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded. No echocardiographic signs of tamponade.\n\nConclusions:\nThe estimated right atrial pressure is 0-10mmHg. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. There is a small pericardial effusion. There is\nan anterior space which most likely represents a fat pad. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: A very small pericardial effusion, without signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n" }, { "category": "Echo", "chartdate": "2133-01-05 00:00:00.000", "description": "Report", "row_id": 66520, "text": "PATIENT/TEST INFORMATION:\nIndication: ?Pericardial effusion. Shortness of breath. Left ventricular function.\nHeight: (in) 63\nWeight (lb): 124\nBSA (m2): 1.58 m2\nBP (mm Hg): 105/70\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 11:50\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: 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%). Normal regional LV systolic function. Estimated\ncardiac index 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. Normal ascending aorta\ndiameter. Normal aortic 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.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Echocardiographic results\nwere reviewed by telephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >65%) Regional\nleft ventricular wall motion is normal. The estimated cardiac index is normal\n(>=2.5L/min/m2). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is a small to moderate sized circumferential pericardial\neffusion measuring 2cm anterior to the right atrium and <1cm anterior to the\nright ventricle, left ventricular apex, and lateral/inferior left ventricle.\nThere are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is new. If clinically indicated, serial evaluation is suggested.\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": "2133-01-06 00:00:00.000", "description": "Report", "row_id": 137820, "text": "Sinus tachycardia. Otherwise, normal tracing. Compared to the previous tracing\nof inverted T waves in lead aVF are now flat. T wave amplitude has\nincreased.\n\n" }, { "category": "ECG", "chartdate": "2133-01-04 00:00:00.000", "description": "Report", "row_id": 137821, "text": "Sinus tachycardia. Non-specific inferior ST-T wave changes. Compared\nto prior tracing of J point elevation in the anterolateral leads\nis less prominent. Otherwise, the rate is faster and other findings are\nsimilar.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-01-08 00:00:00.000", "description": "Report", "row_id": 1502228, "text": "Nursing Progress Note 1900-0700\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Compazine, Phenergen, Percocet\nAccess: RSC/HD line\n\nThis is a 69yo speaking male with a sign. history including esophageal CA s/p chemo/ xrt/ resection (), COPD, DM II, chronic gallstone pancreatitis s/p chole, dysphagia, persistent left sided plueral effusions, trapped left lung, hyperlipidemia. Pt presented to ED with c/o SOB, productive cough, cp x2-3 days, admitted to medical floor where ECHO/CTA showed pericardial effision and r pericardial effusion. On pt dev. resp. distress/hypoxia, rec'd lasix and morphine. Transfered to M/SICU for further management.\n\n\nNuero: Pt speaking only, family at bedside, able to translate. Per pt family, pt is A&Ox3. MAE, follows commands. No c/o pain this shift, no seizure activity noted.\n\n\nCV: HR 80-90s NSR with rare PVCs noted. NBP 95-105s/60-65s. + PP bilaterally.\n\nResp: LS clear to diminished. 3L nc with sats 94-98%. Pt with occasional productive cough, sputum spec sent, results pnding. No SOB/ increased WOB noted.\n\nGI/GU: Abd soft, non-tender to palpation. + BS, no stool this shift. J-tube secure and patent, TF turned on for cyclic feeding at night but will be kept NPO for possible procedure tomorrow.\n\nSkin: WNL\n\nPlan: Pt is called out to medical floor, awaiting bed. Cont. to monitor VS/resp status. Cont. providing suppportive care.\n" }, { "category": "Nursing/other", "chartdate": "2133-01-08 00:00:00.000", "description": "Report", "row_id": 1502229, "text": "Nursing Note:\n\npt remains called out to medical floor, awaiting bed assignment. pts respiratory status and vitals are stable. pts daughter at bedside assisting w/ ADL's. pt/family updated on plan of care. (see transfer note written this shift for further information)\n" }, { "category": "Nursing/other", "chartdate": "2133-01-08 00:00:00.000", "description": "Report", "row_id": 1502230, "text": "Respiratory Care;\nMr. seems much improved since admission. Has \rminimal O2 Requirement.\nGiven ATROVENT x 2 Q6H. NPC. No issues\n" }, { "category": "Nursing/other", "chartdate": "2133-01-09 00:00:00.000", "description": "Report", "row_id": 1502231, "text": "Nursing Progress Note 1900-0700\nPlease see carevue/FHP for additional data.\n\nDispo: FULL code\nAllergies: Compazine, Phenergen, Percocet\nAccess: piv/RtHand\n\nNuero: -speaking, able to answer certain questions appropriately. MAE, follows commands. C/O HA, rec'd 650mg tylenol with little effect. Pt appearing anxious, rec'd 0.5 ativan with good effect. No c/o pain for rest of shift. No seizure activity noted.\n\nCV: HR 80-90s NSR with no ectopy noted. NBP 100-115/70-80s. + PP bilaterally.\n\nResp: LS clear/diminished with intermittent crackles hear in bases. Sats 95-97% on 3L nc. No SOB/ increased WOB noted.\n\nGI/GU: Abd soft, non-tender to palpation. + BS, no stool this shift. J tube secure and patent. TF on for cyclic feeding at night. Foley catheter secure and patent, draining adequate amounts of clear yellow urine.\n\nSkin: WNL\n\nSocial: Family in to visit at start of shift. Did not spend night, updated and questions answered by RN.\n\nPlan: C/O to floor, awaiting bed. Cont. providing supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2133-01-06 00:00:00.000", "description": "Report", "row_id": 1502224, "text": "Nursing Note Cont:\n\npt being evaluated for progression of pericardial effusion, evaulated for pulses paradoxus. possible urgent pericardiocentisis during night if tamponade is thought to develop. notify medical staff is pt becomes tachycardic, or BP drops, or if narrowed pulse pressure exists. presently 32mmHg.\n" }, { "category": "Nursing/other", "chartdate": "2133-01-06 00:00:00.000", "description": "Report", "row_id": 1502225, "text": "Respiratory Care:\npt was hypoxic on the floors and was given diuretics and T/ferred to FIN $ for observation and O2 monitoring.. Diureased >2L and is improved at present.\n" }, { "category": "Nursing/other", "chartdate": "2133-01-07 00:00:00.000", "description": "Report", "row_id": 1502226, "text": "uneventful night for Mr. \n\nNeuro: oriented x 3, denies any pain. Slept most of the night, repositions himself independently.\n\nCV: hemodynamically stable, SR without ectopy. no edema noted, pedal pulses x 4. PIV wnl\n\nRespi: remains on high flow O2 @ 15 lpm with FiO2 of 40%, sats most of the time 93-97%, dipped down 82-85% for few seconds, transiently with sleep. lung sounds clear, crackles bases. Occasional non-productive cough noted. For PPD injection\n\nGI: tube feeds off at 0200, no residuals. Bowel sounds present, non-tender abdomen.No BM this shift.\n\nGU: -500cc for LOS, + 300 since MN.\n\nID: continues on zosyn, afebrile. on contact precaution for MRSA\n\nEndo: on RISS, coverage given.\n\nSkin: intact, no issues\n\nSocial: patient's youngest daughter stayed overnight, acts as interpreter.\n\nplan:\n\nwean down O2 req as tolerated, continue antibiotic therapy, restart tube feeds; monitor for s/s of cardiac tamponade\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-01-07 00:00:00.000", "description": "Report", "row_id": 1502227, "text": "Nursing Note:\n\nNeuro: pt speaking, family at bedside able to translate. per family pt is 3. follows commands, cooperative w/ care. MAEW. c/o headache this AM, received 650mg PO tylenol, pain free since then.\n\nResp: 02 titrated from 0.40 cool neb to 3 L NC at present. sats 93-95. lungs clear upper, RR 15-24. diminished/crackles lower bases. occasional cough. received PPD injection today on r post forearm.\n\nCV: HR 80-100 SR no ectopy. BP 95-110/50-70. pos distal pulses. afebrile. Echo performed today r/t pericardial effusion.\n\nGU: foley intact, UO adequate (see careview)\n\nGI/Endo: abd soft, pos BS, J-tube patent. no BM x several days. pt receives cyclic tube feedings at night but will be kept NPO tonight for possible procedure tomorrow. on humulog sliding scale.\n\nIV: 20g PIV x 2 right and left (painful) hands.\n\nSkin: pt turned and repositioned side to side, no skin breakdown noted.\n\nPlan:\npt is called out to medical floor awaiting bed. cont to monitor resp status, vitals, urine output. labs. cont to update pt/family w/ plan of care as appropriate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-01-06 00:00:00.000", "description": "Report", "row_id": 1502223, "text": "Nursing Note:\n\nAdmit/PMH: see FHP for medical history and admission information.\n\nAllergy: Compazine, Phengergen, Percocet.\n\nNeuro: pt is speaking (speaks little English), family present during day and able to translate. per family pt is 3. pt denies any pain. moves all extremities.\n\nResp: pt presently on 40% hi flow cool neb, FIO2 weaned from 100% NRB upon arrival this morning. sats 95-97, sats noted to drop to 80's when mask removed for expectorating (blood tinged). pt denies dyspnea, RR 20-30. lungs clear upper, crackles RLL, diminished LLL. sputum sample sent for culture. started on vancomycin/zosyn today. pulmonary consulted.\n\nCV: HR 95-120 sinus rhythm, no ectopy. BP stable 98-115/60-70. afebrile. pos distal pulses, edema in lower extremities.\n\nGU: foley cath intact. urine output adequate (see careview), clear yellow. UA and urine culture sent today.\n\nGI/Endo: abd soft, pos BS. J-Tube intact (dsg D/I). cyclic tube feedings to start at 2200 tonight (see order). no BM. on humulog sliding scale, received 4 units today.\n\nIV: 20g PIV x1 left hand.\n\nSkin: skin dry and intact, no breakdown noted.\n\nSocial: pt has 10 children, many family members into visit today. daughter is spokesperson (number on FHP). Family able to help translate.\n\nPlan:\ncont to monitor resp status, cont to attempt to wean FIO2 as pt tolerates.\n\ncont to monitor pts vitals, urine output, labs.\n\ncont to update pt/family on plan of care, cont to provide emotional support to pt.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2189-07-16 00:00:00.000", "description": "Report", "row_id": 1517611, "text": "MICU nursing progress note 7P-7A\nEvents - Pt successfully extubated to 40% FM at 2100, now on RA. No resp distress.\n\nNeuro - Alert, oriented to place, person, events. Thought it was , easily reoriented to date. MAE. C-collar on, logrolling for position change in bed. Denies pain in neck/back/face. Follows commands. Asks about his brother frequently.\n\nResp - Successfully extubated @ 2100. Now on RA, Sats 94-97%. Lungs clear, diminished at bases. RR 17-25. No resp distress. + occ non-prod cough. MDIs by RT.\n\nCV - HD stable, BP 100-127/40-65. HR 100s-113 before extubated when pt was agitated. Has been 80s-90s since extubation, NSR, no VEA. Serial Hcts 34 & 35. CPK 312 ( from 148), MB 3, trop 0.01. HO aware. K 2.9. IVF changed to NS 40K @ 150/hr. 40 Meq PO x 1 given. Recheck K with Hct at 800. Extremities W&D, + distal pulses.\n\nGI - Taking po meds with sips H2O, tol well. Abd soft, +BS. No stool, + flatus. GI prophylaxis Protonix,/carafate. C/o \"mild\" stomach ache. No N/V.\n\nGU - Auto-diuresing 100-300cc/hr. ~ 200cc + yesterday.\n\nID - T max 99.9. BC x 1 sent. Other Cx pending.\n\nPlan - Hct q 6 hrs, next due @ 800 with K. C-collar/C-spine precautions until cleared by team. Monitor for S/S bleeding.\n" }, { "category": "Nursing/other", "chartdate": "2189-07-15 00:00:00.000", "description": "Report", "row_id": 1517608, "text": "Resp care\nPt intubated in ED for protection of his airway & is\nsupported in AC mode, now switched to CPAP/PS mode,\n10 press. supp. 5 peep 40% o2, Vt's- 400, RR-20-27\nw/ good oxygenation. B/S dim w/ exp wheezes treated w/ alb/atro/flovent mdi's. Sx cop. amounts of thick\nbrown secretions. Plan: wean as tol, poss. extubation\n" }, { "category": "Nursing/other", "chartdate": "2189-07-15 00:00:00.000", "description": "Report", "row_id": 1517609, "text": "NPN 2:30p-7p\n\nPlease see Admission Note for further data\n\ncc:\nReview of Systems:\n\n Pt. remains sedated on Propofol gtt at 40mcg/kg/min. Pt. arousable to stimulation. Required additional 3cc boluses of propofol during EGD. PERRLA 2-3mm. C-spine collar d/c'd and team now feels that it needs to be replaced until pt. able to answer questions and cooperate with exam. Pt. kept on log roll precautions until further notice and neck/spine stablized. Plan- ? shut off propofol if passes RSBI/ SBT. Currently, pt. on PSV 10, but did not tolerate PSV 5.\n\nResp- ETT postioned at 23at lip, rotated and retapped upon admission. Of note, pt. with poor dentition, no loose teeth noted. Received on A/C 12X500 100% PEEP 5 with adequate abg; weaned to 40% fio2 following sat's of 100%. See flowsheet for exact ABG values. Pt. currently being trialed on PSV in hopes of extubation tonight. LS- clear throughout with diminshed to bronchial breath sounds on right base. Sx'ing brown, thick secretions.\n\nCV- HR 90's NSR, no ectopy. BP stable 100-130's per NBP cuff. Skin intact. +peripheral pulses. No edema noted. Receiving IVF at 150cc/hr NS.\n\nGI- ABD soft/ + BS. Passing flatus. OGT in good place per team, used for meds and then pulled during EGD. EGD revealing esphogial ulcerations (Barretts)with no active bleeding. No blood noted in stomache, next HCT check at (q 6 hours). No further PRBC given since admission to MICU. Would send coags with next blood draw. Receiving Sucrafate QID as well as protonix QD.\n\nGU- U/O adequate. U/A sent as ordered. Urine tox negative except for benzo's (pt. takes zyprexa at home).\n\nID- 100.8 PR. Hypothermic in ER. No cultures sent in ER. No abx. ordered. Presumed aspiration, received clindamycin in ER.\n\n Brother, present with pt. in ER went home upon admission to MICU available by phone. Pt. lives with MR brother as well in group home, both highly functioning individuals. Per report, brother appears to be coping well and SW is involved.\n" }, { "category": "Nursing/other", "chartdate": "2189-07-15 00:00:00.000", "description": "Report", "row_id": 1517610, "text": "Respiratory Care:\nPt successfully extubated to a 40% cool neb. RR = 21 o2 sat = 100%\nHR = 98 BP = 118/48. Appears comfortable at this time.\n" }, { "category": "Radiology", "chartdate": "2189-07-15 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 799564, "text": " 9:35 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o fracture/ dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fall found down\n REASON FOR THIS EXAMINATION:\n r/o fracture/ dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man with a fall found down.\n\n TECHNIQUE: Helically acquired noncontrast CT scans of the cervical spine were\n obtained and sagittal and coronal reformatted images are provided.\n\n FINDINGS: Spinal alignment is normal. Vertebral body height is preserved.\n No cervical fractures are identified.\n\n There is no evidence of cervical spinal canal stenosis.\n\n There is some stranding in the lung apices. There is sphenoid sinus mucosal\n thickening and fluid in the maxillary sinuses.\n\n IMPRESSION:\n\n No evidence of cervical spine fractures or malalignment.\n\n" }, { "category": "ECG", "chartdate": "2189-07-15 00:00:00.000", "description": "Report", "row_id": 112185, "text": "Sinus rhythm. Inferior non-specific ST-T wave changes. Compared to the previous\ntracing of no significant diagnostic change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2105-10-02 00:00:00.000", "description": "Report", "row_id": 94288, "text": "PATIENT/TEST INFORMATION:\nIndication: ? AORTIC THROMBUS, PFO\nHeight: (in) 70\nWeight (lb): 145\nBSA (m2): 1.82 m2\nBP (mm Hg): 107/\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 16:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.\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. No MVP. Normal mitral valve\nsupporting structures. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\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\nGENERAL COMMENTS: Contrast study was performed with 2 iv injections of 8 ccs\nof agitated normal saline, at rest, and with cough.\n\nConclusions:\nThe left atrium is normal in size. A patent foramen ovale is present (positive\nbubble study at rest). Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF 65%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-02 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1213432, "text": " 9:58 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: ? carotid stenosis\n Admitting Diagnosis: AORTIC THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with + carotid bruits presented with aortic thrombus\n REASON FOR THIS EXAMINATION:\n ? carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old male with carotid bruits and aortic thrombus.\n\n FINDINGS:\n\n RIGHT: B-mode images show no significant atherosclerotic plaque. The common\n carotid waveform is within normal limits with a peak velocity of 138 cm/sec.\n The ICA velocities are 101/20. The ECA velocity is 145. The ICA/CCA ratio is\n 0.9. By velocity criteria, there is no significant stenosis.\n\n LEFT: B-mode images show no atherosclerotic plaque. The common carotid\n waveform is within normal limits and has peak velocity of 247 cm/sec. The ICA\n velocities are 196/42. The ECA velocity is 192. The ICA/CCA ratio is 0.79.\n By velocity criteria, there is suggestion of moderate stenosis, but the\n velocities are diffusely elevated throughout the common carotid system without\n any evidence of significant flow disturbance.\n\n Both vertebral arteries have antegrade, monophasic flow.\n\n IMPRESSION: Elevated common carotid velocities worse on the left compared to\n the right. There is no significant common carotid plaque or bifurcation\n plaque seen. Despite the elevated distal velocities, there is no evidence of\n significant bifurcation stenosis. Recommend complimentary CTA imaging if\n clinically indicated to evaluate the more proximal brachiocephalic\n vasculature.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1213404, "text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassessing ETT\n Admitting Diagnosis: AORTIC THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aortic thrombus\n REASON FOR THIS EXAMINATION:\n reassessing ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate ET tube. Aortic thrombus.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The tip of the endotracheal tube is 5 cm from the carina at the\n level of the clavicular heads. A nasogastric tube courses through the\n esophagus entering into the stomach but extending off the field of view.\n There may be slight right basilar atelectasis but otherwise the lungs are\n clear. No pneumothorax or pleural effusion is present. Cardiac silhouette,\n hilar and mediastinal contours appear normal. Mild interstital edema is\n present.\n\n IMPRESSION: Satisfactory positioning of an ET tube and nasogastric tube.\n\n" }, { "category": "Radiology", "chartdate": "2105-10-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1213517, "text": " 6:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n Admitting Diagnosis: AORTIC THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with leukocytosis, bacteremia, lactic acidosis and PFO with\n confirmed aortic clot, concern for intracranial process\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa FRI 7:58 PM\n PFI: No evidence of acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis, bacteremia, lactic acidosis and patent foramen\n ovale with confirmed aortic clot. Evaluate for acute intracranial process.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast.\n\n COMPARISON: None available.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect or\n recent infarction. Slight prominence of the ventricles and sulci reflects a\n mild degree of generalized atrophy, age related. No concerning osseous lesion\n is seen. Aerosolized secretions are seen within the sphenoid sinuses, left\n greater than right. The mastoid air cells are grossly clear.\n\n IMPRESSION: No evidence of acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1213518, "text": ", W. MED MICU-7 6:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial process\n Admitting Diagnosis: AORTIC THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with leukocytosis, bacteremia, lactic acidosis and PFO with\n confirmed aortic clot, concern for intracranial process\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1213598, "text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: AORTIC THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with persistent cough\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n HISTORY: Persistent cough, question infiltrate.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a small amount of subsegmental atelectasis at both bases.\n The endotracheal tube and feeding tube have been removed. There is no focal\n infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2105-10-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1213378, "text": " 9:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: sp ett check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with sp ett\n REASON FOR THIS EXAMINATION:\n sp ett check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Back pain status post endotracheal and NG tube placement.\n\n TECHNIQUE: Chest radiograph, portable supine single view.\n\n COMPARISON: No prior.\n\n FINDINGS: There is no pneumonia. There is no pleural effusion or\n pneumothorax. Hilar, mediastinal, and cardiac silhouette are within normal\n limits. The endotracheal tube is in appropriate position. The tip of the NG\n tube is projecting at the stomach; however, the sidehole is at the GE\n junction.\n\n IMPRESSION: Endotracheal tube in appropriate position. NG tube tip is\n projecting at the stomach, however, the sidehole is at the GE junction. NG\n tube could be advanced since there is a risk of aspiration with the side hole\n above the GE junction. discussed by phone with at\n 11:30 p.m. on .\n\n" }, { "category": "ECG", "chartdate": "2105-10-02 00:00:00.000", "description": "Report", "row_id": 249570, "text": "Sinus rhythm. RSR' pattern in lead V1 is a normal variant. Premature\nventricular contraction. Compared to the previous tracing of \nventricular ectopy is new.\n\n" }, { "category": "ECG", "chartdate": "2105-10-02 00:00:00.000", "description": "Report", "row_id": 249571, "text": "Normal sinus rhythm. Incomplete right bundle-branch block, previously with\nfusion. No previous tracing available for comparison.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-10-01 00:00:00.000", "description": "Report", "row_id": 249572, "text": "Normal sinus rhythm. Frequent ventricular premature beats. No previous\ntracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-01-10 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 945360, "text": " 10:51 AM\n L-SPINE (AP & LAT) Clip # \n Reason: evaluate instrumentation after lumbar fusion\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate instrumentation after lumbar fusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow up fusion.\n\n AP and lateral views of the lumbosacral spine apparently not obtained upright.\n Since intraoperative exam , the patient has undergone posterior\n osseous fusion of L3-L5 with corresponding pedicle screws, laminectomies, and\n vertical metallic rods. There is an upper lumbar scoliosis but probable\n normal alignment in lateral projection. There is interbody fusion with a\n metallic device at L3-4. No fracture or bone destruction. Multiple unusual\n calcifications overlie the left mid abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-01-06 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 944905, "text": " 3:00 PM\n L-SPINE (AP & LAT) Clip # \n Reason: L4-L5 POSTERIOR FUSION\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n HISTORY: L4-L5 fusion.\n\n Four views demonstrate posterior fusion of the third, fourth and fifth lumbar\n vertebra. There are 2 pedicle screws in place at each level. There are\n connected by 2 rods. There is evidence of post-surgical change involving the\n endplates surrounding the L3-4 disc space. Metallic density interspace fusion\n device is present at that level anteriorly and L4 screws appear to extend into\n that space in the lateral projection.\n\n IMPRESSION: Post-surgical changes as described. Limited study.\n\n" }, { "category": "Radiology", "chartdate": "2152-12-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 943844, "text": " 2:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check picc tip position. #4f, sl, 52cm, v-cath picc f\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with septicemia\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #4f, sl, 52cm, v-cath picc for abx. please page\n beeper # with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Septicemia, PICC line placed, check position.\n\n The tip of the PICC line lies at the SVC-RA junction. Some elevation of the\n right hilus is present and increased densities in the right upper lobe are\n seen suggesting some fibrosis in this region. The lung fields are otherwise\n clear. There is no evidence of failure. IV team informed.\n\n\n" }, { "category": "Echo", "chartdate": "2152-12-29 00:00:00.000", "description": "Report", "row_id": 84630, "text": "PATIENT/TEST INFORMATION:\nIndication: MRSA bacteremia. R/o endocarditis.\nBP (mm Hg): 130/71\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 14:25\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 or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nAORTA: Simple atheroma in aortic arch. 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: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(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 monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. There is\nmild to moderate regional left ventricular systolic dysfunction with anterior\nhypokinesis (segmental wall motion was not fully assessed). There are simple\natheroma in the aortic arch and in the descending thoracic aorta. The aortic\nvalve leaflets (3) are mildly thickened. No masses or vegetations are seen on\nthe aortic valve. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. No mass or vegetation is seen on the mitral valve. Trace\nmitral regurgitation is seen.\n\nNo vegetation or abscess seen.\n\n\n" }, { "category": "ECG", "chartdate": "2153-01-03 00:00:00.000", "description": "Report", "row_id": 207125, "text": "Sinus rhythm\nLow amplitude lateral T waves - are nonspecific and may be within normal limits\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2153-01-05 00:00:00.000", "description": "Report", "row_id": 1410671, "text": "NPN77-1900 addendum\nGI; pt had sm bm today.\n\nIV: L AC PIV infiltrated during blood tx-IV D/C and hotpack applied, arm elevated. PICC used to finish tx. Swelling had decreassed substantially by end of shift.\n\n" }, { "category": "Nursing/other", "chartdate": "2153-01-06 00:00:00.000", "description": "Report", "row_id": 1410672, "text": "NPN, 1900-0700\nNEURO: AAO x 3, anxious, cooperative. No focal deficits, no paratheses or tremors of extremities.\n\nCV: NSR, rare AEA, VEA, 80-100's. SBP 120-140's. Pulses palpable throughout; no edema. Pboots.\n\nPulm: NP 2l sats > 95%, drop to 88-90 on RA when asleep. BS course anteriorly, clear w/ cough, non-productive. Dim bases, L>R. IS to 1500 w/ encouragement.\n\nGI: abd soft, non-tender; hypo BS. Gitube site clean; patent for meds. Soft brown, heme neg stool x 2, incontinent. NPO.\n\nRenal: F/C urine clear amber, OP adequate. Labs wnl, lytes repleted.\n\nSkin: duoderm over stage 2 sore on coccyx, skin otherwise intact. PICC right arm clean and patent. Left flank dressing C/D.\n\nID: WBC wnl, afebrile, cont on vanco. MRSA, VRE of spine.\n\nEndo: RISS, well controlled.\n\nHeme: Hct 29 this am.\n\nP: awaiting surgery today for remainder of spinal fusion for osteomyelitis....then to PACU-->>SICU\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-01-06 00:00:00.000", "description": "Report", "row_id": 1410673, "text": "TSICU Nursing Progress Note\nNeuro - Pt 3, pleasant, anxious. Participating in care. Moves all extremities. c/o back and incisional pain, medicated with dilaudid sc.\n\nCV - HR 80s to 90s, NSR. Occ PVCs. ABP 110s to 130s by arterial line. Peripheral pulses palpable.\n\nResp - Lungs CTA, dim in bases. Weak cough. IS with encouragement. O2 2L NC with O2 sats > 95%.\n\nGI - Abdomen soft, tender near incision. Feeding tube used for meds, flushes easily. Smears of soft brown stool x2.\n\nGU - Clear yellow urine via foley.\n\nEndo - No sliding scale insulin coverage needed.\n\nA - Stable hemodynamics awaiting OR.\n\nP - OR for posterior fusion.\n" }, { "category": "Nursing/other", "chartdate": "2153-01-07 00:00:00.000", "description": "Report", "row_id": 1410674, "text": "TSICU Nursing Progress Note\nNeuro - Pt sleeping in long naps throughout night. When aroused will open eyes to voice, A&O x1-2. Follows commands with all extremities, however weak throughout. Pt reports pain in back and BLE's. Currently with epidural in place with bupivicane at 8cc/hr, unable to get reliable level from pt. However he does say his pain is better since the epidural has been started. Also receiving intermittent dilaudid for pain as well with + effect.\n\nCV - HR 80-110 sinus rhythm, with occasional PVC's. ABP 90-130 systolic. + peripheral pulses, skin warm and dry. Lytes repleated PRN.\n\nResp - Lungs clear throughout, diminished at the bases. Currently with cool mist face tent 50% Fio2 maintaining sats 100%. Denies difficulty breathing or shortness of breath.\n\nGI - Abdomen soft, nt/nd. + bowel sounds throughout. NPO. use G-tube for meds only. No BM overnight, 1 small smearing.\n\nGU - Foley draining clear yellow urine in adequate amounts most of night. Urine output did drop off at one point and pt was given 500cc bolus of NS with small increase in urine output.\n\nEndo - No insulin needed per RISS.\n\nId - Tmax 100.9 oral, currently down to 99.0. Pt remains on vancomycin. + MRSA in back wound.\n\nSkin - Back dressing intact, primary OR dressing, no drainage noted. epidural site behind dressing, unable to fully assess epidural site. Abdominal incision C&D with steri strips in place, no drainage. Duoderm on coccyx, remains intact.\n\nPsych/social - Wife in at beginning of shift. She was able to reorient and calm pt when coming out of OR. She is staying at the Holiday Inn. Pt and family from . Pt at times anxious, however redirectable.\n\nA - s/p anterior/posterior fusion L3-5. acute pain, impaired mental status. risk for infection.\n\nPlan - Continue to monitor per routine. Continue to monitor and treat for pain PRN. ? start feedings. ?transfer to floor. Continue to update pt and family of current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2153-01-05 00:00:00.000", "description": "Report", "row_id": 1410669, "text": "NPN, 1900-0700\nneuro: AAO x 3; anxious, cooperative. Moves all extremities; focal exam WNL. Pt cont w/ mild right UE intention tremors. HOB maintained 30 degrees or less. Med x 3 w/ dilaudid w/ fair effect; pt still splints resp and cough when painfree.\n\nCV: NSR, no VEA, 80-90's. SBP 120's-140's at rest. No edema.\n\nPulm: BS CTAb, diminished bibasilar, L>R. CDB encouraged, pt very reluctant. Unable to effectively use IS. Sats>95% on NP 3L\n\nGI: abd soft, non-tender; BS hypoactive. G-tube patent, used for meds. NPO. No N/V. Scant soft brown stoolo, heme neg.\n\nRenal: F/C urine clear amber, OP adequate. NS @ 100cc/hr. Labs pending\n\nSkin: compression dressing over left flank D/I. Minor abrasion coccyx area;barrier cream appled. PICC RAC clean and patent. A-line right radius positional, site WNL.\n\nID: WBC pending. Tmax 98\n\nEndo: RISS, none required.\n\nPsychosocial: wife in last eve; appropriate and supportive. She is staying at Holiday Inn (they are from ) and will call this am for status report.\n\nP: transfer to ortho floor today. Follow neuro exam, provide adequate analgesia. Bronchial hygeine; strongly encourage CDB, IS\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-01-05 00:00:00.000", "description": "Report", "row_id": 1410670, "text": "TSICU-NPN:0700-1900\nNeuro: Neuros remain intact, pt is A/Ox3 and following commands. Denies numbness/tingling in extremities, and MAEs appropriately. IV Dilaudid given twice today with good pain control.\n\nCV: ABP 100's-130's sys., NIBP correlating appropriately. HR NSR 80's. +pp, +csm.\n\nResp: pt continues on 3L NC, O2 sats 100%. Pt briefly desated twice to 70% (with NC on) while talking, but sats immediately returned to 100%. Lung sounds clear and equal, dim at bases. Pt using IS well with RN assist up to 1200.\n\nGI: And soft and non-distended, BS hypo. PEG clamped-NPO for possible OR today (now ?tomorrow)-meds given through PEG/flushes well.\n\nRenal: Foley draining clear yellow urine in adequate amts.\n\nHeme: Pt is receiving his last of 2 units of blood. Hct 25-Ortho/Spine ordered. No reaction noted.\nSkin: Elastoplast/post op dsg remains clean and intact (anterior site). Sm pressure sore noted on upper left bottock/coccx-duoderm applied-pt turned Q2. Protective cream applie to back and peri areas.\n\nEndo: BS per RISS.\n\nID: ID following and in to see pt today-will continue on Vanco at home. Lab test thus far have been neq (per ID). Pt continues on Vanco and has been afeb.\n\nSocial: wife in to visit and has spoken with Ortho and ID MDs-staying at Holiday Inn.\n\nPOC: ? OR for posterior fusion tomorrow\n encourage IS/deep breathing\n update family on POC\n maintain skin integrity/monitor pressure ulcer\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-01-04 00:00:00.000", "description": "Report", "row_id": 1410668, "text": "TSICU Admit Note\n79 yo male with extensive medical hx including CAD s/p stenting, diet controlled DM, DJD, back pain, BPH with recurrent UTI s/p TURP, FTT s/p TF placement and anxiety disorder. Hx MRSA UTIs and bacteremia. After c/o back pain was dx with MRSA osteomyelitis/discitis/paraspinal abcess. Tx to for surgical tx. To OR today for anterior fusion with instrumentation of T3-5. Will go for posterior fusion on Saturday.\n\nMinimal blood loss in OR. To TSICU for monitoring overnoc. Extubated on arrival to TSICU.\n\nROS -\n\nNeuro - Pt alert, disoriented. Pulling at wires, O2 mask, restrained. Moving bilateral arms with normal strength. Moving bilateral legs weakly. HOB < 30 degrees.\n\nCV - HR 80s to 90s, no ectopy. Hypertensive on extubation with SBP 160s. SBP 130s when restful. Peripheral pulses palpable. No edema.\n\nResp - Lungs essentially clear. Pt refuses to cough. Face tent at 50% for O2 sats 100%.\n\nGI - Abdomen soft, flat. G-tube in place. + BS, no BM.\n\nGU - Foley draining clear yellow urine in adequate amounts.\n\nSocial - Daughter called. contact from wife.\n\nA - Resp status stable post-extubation.\n\nP - Continue to monitor resp status. Medicate for pain. Continue to support.\n" }, { "category": "Radiology", "chartdate": "2153-01-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 944464, "text": " 6:15 PM\n CHEST (PA & LAT) Clip # \n Reason: preop\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with septicemia, preop for vertebral rod fixation\n\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male with septicemia. Preop evaluation for vertebral\n rod fixation.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: The heart size is normal. There is tortuosity of the\n thoracic aorta. Linear opacity at the right lung apex with associated\n elevation of the right hilus is suggestive of underlying fibrosis in this\n region. The lung fields are otherwise clear. There is no pneumothorax or\n pleural effusion. The pulmonary vasculature is not congested. Degenerative\n change is noted in the mid thoracic spine. The tip of a right PICC terminates\n in the mid SVC.\n\n IMPRESSION: Right apical linear opacity likely representing fibrosis. No\n pneumonia or CHF.\n\n" }, { "category": "Radiology", "chartdate": "2153-01-02 00:00:00.000", "description": "PROSTATE U.S.", "row_id": 944315, "text": " 1:44 PM\n PROSTATE U.S. Clip # \n Reason: prostate abscess\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p TURP, now with recurrent MRSA bacteremia, please eval for\n prostate abscess\n REASON FOR THIS EXAMINATION:\n prostate abscess\n ______________________________________________________________________________\n FINAL REPORT\n PROSTATE ULTRASOUND\n\n CLINICAL INDICATION: 79-year-old male status post TURP with recurrent MRSA\n bacteremia, to evaluate for possible prostate abscess.\n\n Transrectal scans of the prostate were performed demonstrating a relatively\n normal sized prostate with mild BPH. There is extensive calcification along\n the surgical capsule, but there are no masses or fluid collections seen to\n suggest abscess. The seminal vesicles are normal and symmetrical in\n appearance bilaterally. Color flow imaging shows no focal areas of\n hypervascularity.\n\n CONCLUSION: Mild BPH. No son evidence of mass or abscess.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-01-04 00:00:00.000", "description": "O L-SPINE (AP & LAT) IN O.R.", "row_id": 944625, "text": " 2:30 PM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: ANT FUSION L3-L5\n Admitting Diagnosis: SEPTICEMIA\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE, FOUR VIEWS\n\n INDICATION: Anterior fusion at L3-L5.\n\n FINDINGS: A series of four intraoperative radiographs of the lumbar spine\n were obtained. These demonstrate an anterior interbody fusion device placed\n in the lumbar spine at L3-L4. Severe multilevel degenerative changes in\n lumbar spine are seen. Evaluation of osseous structures is obscured by\n overlying bowel contents. Retractors are seen anteriorly. Please refer to\n operative report for full details.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-01-02 00:00:00.000", "description": "PERSANTINE MIBI", "row_id": 944231, "text": "PERSANTINE MIBI Clip # \n Reason: OSTEO/ PRE-OP STRATIFICATION\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 10.2 mCi Tc-m Sestamibi Rest ();\n 30.9 mCi Tc-99m Sestamibi Stress ();\n HISTORY: 79 year old male with type II DM and SOB, referred for evaluation\n prior to non-cardiac surgery.\n\n\n SUMMARY OF DATA FROM THE EXERCISE LAB:\n\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min.\n\n METHOD:\n\n Resting perfusion images were obtained with Tc-m sestamibi. Tracer was\n injected approximately one hour prior to obtaining the resting images.\n\n Two minutes after the cessation of infusion of dipyridamole, approximately three\n times the resting dose of Tc99m sestamibi was administered IV. Stress images\n were obtained approximately one hour following tracer injection.\n\n Imaging protocol: Gated SPECT.\n\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n INTERPRETATION:\n\n The image quality is good.\n\n Left ventricular cavity size is normal.\n\n Rest and stress perfusion images reveal uniform tracer uptake throughout the\n left ventricular myocardium.\n\n Gated images reveal slight apical hypokinesis.\n\n The calculated left ventricular ejection fraction is 49 %.\n\n No prior studies are available for comparison.\n\n IMPRESSION:\n 1. No definite reversible perfusion defects identified. 2. Slight apical\n hypokinesis with low-normal calculated LVEF of 49%.\n\n\n (Over)\n\n PERSANTINE MIBI Clip # \n Reason: OSTEO/ PRE-OP STRATIFICATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n , M.D.\n , M.D. Approved: WED 4:00 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": "2152-12-28 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 943665, "text": " 12:40 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: please eval for abscess\n Admitting Diagnosis: SEPTICEMIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with history of MRSA discitis L3/L4, presents with persistent\n bacteremia, back pain\n REASON FOR THIS EXAMINATION:\n please eval for abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of MRSA discitis at L3-4 with persistent bacteremia and\n back pain. Evaluate for abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the cervical, thoracic\n and lumbar spines were obtained. Post-gadolinium images were also obtained.\n\n MRI OF THE CERVICAL SPINE: There is loss of disc height at C6-7. The\n alignment is grossly normal. There is no abnormal signal within the vertebral\n bodies or intervertebral discs to suggest discitis or osteomyelitis within the\n cervical spine. There is disc desiccation at multiple levels. No pre- or\n paravertebral abnormal signal is seen. There is no evidence of cord\n compression and no abnormal signal is seen within the cervical spinal cord.\n\n MRI OF THE THORACIC SPINE: The alignment is normal. There is increased STIR\n signal present within the T10-11 intervertebral discs and the adjacent\n superior endplate at T11. There is also associated enhancement of the T10-11\n intervertebral disc, and also possibly at the peripheral margins of the region\n of abnormal signal present within the superior endplate of T11. No abnormal\n signal is seen within the spinal cord. There is no evidence of epidural\n abscess. There is no evidence of cord compression or significant\n neuroforaminal stenosis within the thoracic spine.\n\n MRI OF THE LUMBAR SPINE: There is increased T2 signal present within the L3-4\n intervertebral disc. There is adjacent endplate irregularity of the inferior\n endplate of L3 and superior endplate of L4. There is enhancement seen on\n post-gadolinium images at the L3-4 intervertebral level with also associated\n pre- and paravertebral enhancement at these levels consistent with\n infectious/phlegmonous change. There is no evidence of epidural abscess at\n this level. There is narrowing of the lateral recesses at L3-4 and moderate\n spinal stenosis, predominantly due to thickening of the ligamentum flavum.\n Notably also, there is the appearance of peripheral clumping of the cauda\n equina nerve roots seen at L5 suggestive of arachnoiditis. Conus medullaris\n terminates at L1. Note is made of a rounded T2 hyperintense focus at the\n lower pole of the right kidney measuring 13 mm consistent with a cyst. There\n appears to be fatty replacement of the posterior paraspinal musculature.\n\n IMPRESSION:\n (Over)\n\n 12:40 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: please eval for abscess\n Admitting Diagnosis: SEPTICEMIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Discitis-osteomyelitis at L3-4 with pre- paravertebral inflammatory change\n with no evidence of epidural abscess at this location. Clumping of the cauda\n equina nerve roots suggests arachnoiditis.\n 2. STIR signal hyperintensity and enhancement at the T10-11 intervertebral\n disc and superior endplate of T11, also suspicious for discitis-osteomyelitis,\n also with no evidence of epidural abscess at this location.\n\n The above was discussed with Dr. at approximately 5:00 p.m. on\n .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2188-06-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1142519, "text": " 8:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with basal ganglia bleed on OSH, unable to upload.\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:42 PM\n 12 x 10 hemorrhagic focus in the left basal ganglia, without significant mass\n effect. No intraventricular extension. No SAH.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old man with basal ganglia on outside hospital study.\n Unable to be uploaded. Now evaluate for intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT images were acquired from the brain.\n\n FINDINGS: There is a hyperdense focus in the left basal ganglia, measuring 12\n x 10 mm (image 2:18), with a small extension to corona radiata, representing\n an acute hemorrhagic focus. Peri-hemorrhagic edema is mild, without\n significant mass effect on adjacent parenchyma.\n\n The ventricles and sulci remain prominent but symmetric in size. There is no\n shift of normally midline structures. Mild periventricular white matter\n hypodensities are compatible with chronic microvascular ischemic disease. The\n -white matter differentiation is preserved. Scattered ethmoidal opacities\n are noted. A small polypoid mucosal thickening in the right maxillary sinus\n likely represents a mucous retention cyst. The left maxillary sinus is clear.\n The mastoid air cells are clear. No acute fracture is noted.\n\n IMPRESSION:\n 1. 12 x 10 mm hemorrhagic focus in the left basal ganglia, without\n significant mass effect, midline shift, intraventricular extension or\n subarachnoid hemorrhage. Most likely etiology is hypertension.\n\n 2. Global atrophy with mild chronic microvascular ischemic disease.\n\n" }, { "category": "ECG", "chartdate": "2188-06-06 00:00:00.000", "description": "Report", "row_id": 236797, "text": "A-V paced rhythm with probable ventricular fusion complexes. Since the previous\ntracing of left and right arm leads are now in normal position.\nOtherwise, there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2188-06-05 00:00:00.000", "description": "Report", "row_id": 236798, "text": "Atrial pacing and pseudofusion with sinus rhythm. Right and left arm lead\nreversal. Right bundle-branch block. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2184-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1223287, "text": " 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p cardiac arrest, now unresponsive without any sedation.\n Intubated at OSH.\n REASON FOR THIS EXAMINATION:\n ? intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc 9:07 PM\n Global loss of grey white differentiation, concerning for global hypoxia.\n WET READ VERSION #1 LLTc 8:20 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac arrest.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without\n the use of IV contrast. Additional 2-mm coronal and sagittal reformations\n were obtained.\n\n FINDINGS: There is global loss of the grey white matter differntiation,\n concerning for global hypoxia. There is no evidence of acute intracranial\n hemorrhage, edema, mass, mass effect. The ventricles and sulci are moderately\n prominent, compatible with diffuse cortical atrophy. There is no shift of\n normally midline structures. No acute fracture is detected. Secretions are\n seen within the nasopharynx, likely secondary to a recent intubation.\n\n IMPRESSION: Global loss of grey white differentiation, concerning for global\n hypoxia.\n\n" }, { "category": "Radiology", "chartdate": "2184-01-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1223297, "text": " 8:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: central line placement confirmation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p arrest\n REASON FOR THIS EXAMINATION:\n central line placement confirmation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:26 P.M., \n\n HISTORY: 83-year-old man after cardiopulmonary arrest. Check central venous\n line placement.\n\n IMPRESSION: AP chest compared to , 6:50 p.m.:\n\n ET tube is in standard placement. Right jugular line ends in the upper SVC.\n No pneumothorax or mediastinal widening. Small-to-moderate bilateral pleural\n effusions have increased since earlier this evening, probably due to a heart\n failure. Heterogeneous opacification throughout the lungs can be explained by\n severe emphysema with or without pulmonary fibrosis and concurrent pulmonary\n edema. Of course, pneumonia could be present but not recognize. The heart is\n normal size. Nasogastric tube ends in the low esophagus and would need to be\n advanced 15 cm to move all the side ports into the stomach, and the proximal\n redundancy of the tube in the hypopharynx needs to be withdrawn.\n\n [The patient had expired by the time this formal report was transcribed.]\n\n" }, { "category": "Radiology", "chartdate": "2184-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223286, "text": " 6:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placement, acute chest process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p cardiac arrest, sent from OSH. Now intubated.\n REASON FOR THIS EXAMINATION:\n ? ETT placement, acute chest process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac arrest, sent from outside hospital, now\n intubated.\n\n COMPARISON: None.\n\n PORTABLE AP VIEW OF THE CHEST: Endotracheal tube tip terminates approximately\n 3 cm from the carina. An orogastric tube tip terminates just beyond the\n gastroesophageal junction, and should be advanced for optimal positioning.\n The heart size is top normal. Diffuse ill-defined alveolar opacities are\n noted, most predominantly in the perihilar regions, left lung more involved\n than the right. There is blunting of the costophrenic angles bilaterally,\n which may reflect small effusions. No pneumothorax identified. A large bulla\n appears to be present in the right lower lobe, and severe emphysematous\n changes are noted.\n\n IMPRESSION:\n 1. Endotracheal tube in standard position. The orogastric tube tip\n terminates just beyond the gastroesophageal junction and should be advanced\n further for optimal positioning.\n 2. Diffuse airspace opacities in both lungs, primarily in the perihilar\n regions. Findings suggestive of moderate pulmonary edema, though, multifocal\n infection is not excluded. Probable small bilateral pleural effusions.\n 3. Severe emphysema.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2184-01-20 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1223291, "text": " 7:41 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE or other cause for cardiac arrest\n Field of view: 36 Contrast: VISAPAQUE Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p cardiac arrest, unknown cause. RV appears large on bedside\n US.\n REASON FOR THIS EXAMINATION:\n ? PE or other cause for cardiac arrest\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc 8:31 PM\n 1. Severe pulmonary edema superimposed on severe emphyesma.\n 2. Bilateral bibasilar consolidations and atalectasis.\n 3. No PE detected to the subsegmental levels. No dissection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest of unknown cause.\n\n COMPARISON: Chest radiograph available from .\n\n TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained\n following the uneventful administration of 70 ml of Visipaque intravenous\n contrast. Coronal and sagittal reformations were performed at 5-mm slice\n thickness. Additional right and left oblique reconstructions were obtained\n for further evaluation of the pulmonary vasculature.\n\n CHEST CT WITH IV CONTRAST:\n An endotracheal tube terminates at the lower trachea. An orogastric tube\n terminates at the gastroesophageal junction (3:107). The right ventricle is\n mildly enlarged. Minimal aortic valvular and mild coronary arterial\n calcifications are present. No gross definite dissection is seen within the\n aorta, although intraluminal evaluation is limited due to contrast timing. No\n intramural hematoma is present, and the aorta is normal in caliber. The main\n pulmonary arteries are dilated, measuring up to 3.8 cm in diameter (3:56),\n compatible with pulmonary arterial hypertension. No pulmonary embolus is\n detected to the subsegmental level. A trivial pericardial effusion is present.\n\n Severe emphysema is present, worst at the lung apices. There is superimposed\n severe pulmonary edema, with gravity-dependent density gradients and extensive\n dependent consolidations bilaterally (3:64), the latter likely reflecting\n alveolar fluid and atelectasis. There is no pneumothorax. Left apical\n curvilinear calcification is noted.\n\n Contrast refluxes into the hepatic veins (3:105). Perihepatic ascites is\n present (3:109).\n\n OSSEOUS STRUCTURES: Multiple acute bilateral anterior rib fractures are\n present (3:67, 75, 86, 104). There is a nondisplaced sternal fracture\n (602A:34). Old right posterior rib fractures are also seen (3:42, 44).\n\n IMPRESSION:\n (Over)\n\n 7:41 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE or other cause for cardiac arrest\n Field of view: 36 Contrast: VISAPAQUE Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Severe emphysema with superimposed severe pulmonary edema. Large\n dependent bilateral consolidations, likely reflect fluid-filled alveolar\n spaces, though aspiration and infection cannot be excluded.\n 2. Enlarged pulmonary arteries, compatible with pulmonary arterial\n hypertension, and right ventricular enlargement. No pulmonary embolus.\n 3. Acute bilateral anterior rib and sternal fractures, secondary to chest\n compressions.\n 4. Orogastric tube terminating at the gastroesophageal junction and should be\n advanced. Positioning of the orogastric tube was communicated by Dr. to\n Dr. via telephone at 10PM .\n 5. Perihepatic ascites.\n\n\n\n" }, { "category": "ECG", "chartdate": "2184-01-20 00:00:00.000", "description": "Report", "row_id": 247764, "text": "Sinus rhythm. The P-R interval is prolonged. Left axis deviation. Right\nbundle-branch block with left anterior fascicular block. Q waves in the\ninferior leads consistent with myocardial infarction. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2108-09-25 00:00:00.000", "description": "Report", "row_id": 104413, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Hypertension. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 10:02\nTest: TEE (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. No spontaneous echo contrast or\nthrombus in the LA/LAA or the RA/RAA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal diameter of aorta at the sinus, ascending and\narch levels.\n\nAORTIC VALVE: Normal 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.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. The TEE probe was passed with assistance from the\nanesthesioology staff using a laryngoscope. No TEE related complications.\n\nConclusions:\nPreBypass:\nThe left atrium and right atrium are normal in cavity size. No spontaneous\necho contrast or thrombus is seen in the body of the left atrium/left atrial\nappendage or the body of the right atrium/right atrial appendage.\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%).\nRight ventricular chamber size and free wall motion are normal.\nThe ascending, transverse and descending thoracic aorta are normal in diameter\nand free of atherosclerotic plaque. The diameters of aorta at the sinus,\nascending and arch levels are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nPostBypass:\nPatient is A-Paced on a phenylephrine infusion.\nLV function is normal, no WMA, estimated EF-55%.\nMR remains trace.\nThe remainder of the exam is unchanged.\nThere is no echocardiographic evidence of aortic dissection post\nde-cannulation.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1253288, "text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: Patient with CABG, chest tube removal.\n\n COMPARISON: .\n\n FINDINGS:\n\n Since prior exam the patient has been extubated. Mediastinal, chest tubes, NG\n tube has been removed. There is no pneumothorax. Left lower lobe atelectasis\n is slightly increased. Mediastinal and cardiac contours moderate enlargement\n is stable considering the different technique. Right jugular line ends in the\n lower SVC. There is no pneumothorax. Pleural effusion is small if any.\n\n CONCLUSION:\n\n There is no pneumothorax after chest tube removal.\n Left lower lobe atelectasis has slightly increased.\n\n" }, { "category": "Radiology", "chartdate": "2108-10-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1253768, "text": " 11:12 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions, atx\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with s/p CABG, WBC ^ing\n REASON FOR THIS EXAMINATION:\n f/u effusions, atx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Minimal left pleural effusion with left retrocardiac atelectasis,\n borderline size of the cardiac silhouette. Sternal wires in unchanged and\n correct position. Minimal plate-like atelectasis at the right lung base. No\n evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-19 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1252424, "text": " 4:25 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CAD, pre-op for CABG\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pre-operative for CABG.\n\n FINDINGS: No previous images. Cardiac silhouette is at the upper limits of\n normal in size and there is tortuosity of the aorta. No definite vascular\n congestion, pleural effusion, or acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-21 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1252634, "text": " 8:53 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op, carotid disease?\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with three-vessel disease, for CABG\n REASON FOR THIS EXAMINATION:\n pre-op, carotid disease?\n ______________________________________________________________________________\n FINAL REPORT\n \n Department of Radiology\n Standard Report- Carotid Series Complete\n\n Reason: 69 year old woman with three-vessel disease, pre/op CABG.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is no plaque in the ICA. On the left there is mild\n heterogeneous plaque in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 75/19, 74/28, 57/23, cm/sec. CCA peak systolic\n velocity is 83 cm/sec. ECA peak systolic velocity is 70 cm/sec. The ICA/CCA\n ratio is .90. These findings are consistent with no stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 63/24, 77/32, 39/16, cm/sec. CCA peak systolic\n velocity is 68 cm/sec. ECA peak systolic velocity is 80 cm/sec. The ICA/CCA\n ratio is 1.1. These findings are consistent with <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA with no stenosis.\n Left ICA with <40% stenosis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1253492, "text": " 2:12 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST RADIOGRAPH DATED \n\n COMPARISON: Chest radiographs dating between and .\n\n FINDINGS: The patient is status post recent median sternotomy and coronary\n artery bypass surgery. Stable post-operative widening of the\n cardiomediastinal contours. No evidence of pulmonary edema. Slightly\n improved left retrocardiac atelectasis but apparent worsening of right\n retrocardiac atelectasis. Small bilateral pleural effusions are present,\n there is no evidence of a pneumothorax.\n\n IMPRESSION: Post-operative widening of cardiomediastinal contours.\n Retrocardiac atelectasis and small pleural effusions, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-09-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1253073, "text": " 1:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CHEST PAIN;SHORTNESS OF BREATH;ABNORMAL STRESS TEST\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CAD s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 69-year-old female patient with coronary artery disease status\n post bypass surgery, fast track extubation cardiac surgery portable.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. The patient is now intubated, the ETT terminating in the\n trachea some 3 cm above the level of the carina. An NG tube reaches well\n below the diaphragm including the side port. A right internal jugular\n approach central venous line reaches 2 cm below the carina overlying the lower\n SVC. There are two mediastinal drainage tubes from below and a left-sided\n chest tube terminating in the left lateral pleural sinus. No significant\n pleural effusions can be identified as the lateral pleural sinuses remain\n free. Both lungs are well aerated without evidence of pneumothorax.\n\n IMPRESSION: Satisfactory first postoperative chest findings.\n\n\n" }, { "category": "ECG", "chartdate": "2108-09-25 00:00:00.000", "description": "Report", "row_id": 306432, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthe rate has increased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2108-09-18 00:00:00.000", "description": "Report", "row_id": 306433, "text": "Sinus rhythm. Within normal limits. No previous tracing available for\ncomparison.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2157-11-18 00:00:00.000", "description": "Report", "row_id": 73978, "text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nHeight: (in) 74\nWeight (lb): 200\nBSA (m2): 2.18 m2\nBP (mm Hg): 137/61\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 13:37\nTest: Portable TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Saline\nTechnical Quality: Good\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\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 AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve.\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 sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by lidocaine spray. No TEE related\ncomplications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. Contrast study was performed with 3 iv\ninjections of 8 ccs of agitated normal saline, at rest, with cough and\npost-Valsalva maneuver. The patient appears to be in sinus rhythm.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\n1. No spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect or patent foramen ovale is seen by 2D,\ncolor Doppler or saline contrast with maneuvers.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. No cardiac source of embolism identified.\n\n\n" }, { "category": "Echo", "chartdate": "2157-11-15 00:00:00.000", "description": "Report", "row_id": 73979, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 74\nWeight (lb): 200\nBSA (m2): 2.18 m2\nBP (mm Hg): 153/73\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 11:00\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting 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. Mildly dilated ascending aorta.\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\ntricuspid valve supporting structures.\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: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nPatient was unable to cooperate with maneuvers.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF 70%). No\nmasses 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. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nThere is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , no major change is evident.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848264, "text": " 8:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement, ptx\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p left subclavian central line placement\n REASON FOR THIS EXAMINATION:\n line placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n CLINICAL INDICATION: Subclavian line placement.\n\n There are no prior films for comparison.\n\n A left subclavian vascular catheter is in satisfactory position within the\n superior vena cava. There is no evidence of pneumothorax. An endotracheal\n tube is in satisfactory position and a nasogastric tube is in satisfactory\n position and a nasogastric tube coiled cephalad in the fundus. Cardiac and\n mediastinal contours are normal. There are patchy and linear perihilar and\n retrocardiac opacities bilaterally suggestive of atelectasis. No pleural\n effusions are evident.\n\n IMPRESSION:\n 1) Central venous catheter are in satisfactory position with no pneumothorax.\n\n 2) Bilateral perihilar and retrocardiac opacities, most suggestive of\n atelectasis. A component of aspiration cannot be excluded in the appropriate\n clinical setting.\n\n" }, { "category": "Radiology", "chartdate": "2157-11-16 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 848577, "text": " 9:39 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evaluate for difficulty swallowing/aspiration risk\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with R MCA infact.\n REASON FOR THIS EXAMINATION:\n evaluate for difficulty swallowing/aspiration risk\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right middle cerebral artery infarct, difficulty swallowing and\n aspiration risks.\n\n OROPHARYNGEAL VIDEO FLUOROSCOPIC SWALLOW: An oral and pharyngeal swallowing\n video fluoroscopy study was performed in collaboration with the speech and\n swallow therapist. Thick liquid, nectar thick liquid, pureed consistency\n barium, one cookie coated with barium, dual consistency barium, barium coated\n bagel and one barium pill were administered.\n\n The oral phase showed overall mild to moderate deficits with decreased bolus\n control and formation. There was prolonged mastication and anterior spillage\n of both liquid and purees. The patient did have premature spill over liquids\n in the pyriform sinuses and valleculae intermittently.\n\n The pharyngeal phase was noted for mild delay in swallow initiation which\n appear to be influenced by the patient's mental status. The rest of the\n anatomic movements were unremarkable. Barium tablet did pass freely to the\n esophagus and stomach once the patient transferred the tablet from his mouth\n to the pharynx. There is mild vallecular residue noted with both solids and\n liquids.\n\n Mild penetration occurred before the swallows of nectar and thick liquids due\n to a delay in swallow initiation. Mild to moderate aspiration occurred before\n the swallow with nectar, thick liquids and thin liquids. Aspiration occurs as\n a delay in swallowing initiation, which was eliminated with larger boluses.\n There is spontaneous cough response noted for aspiration of nectar and thick\n liquids.\n\n IMPRESSION:\n Mild to moderate oral and pharyngeal dysphagia with noted oral weakness\n contributing to oral residue and bolus loss. Mild aspiration with nectar\n thick liquids with mild to moderate aspiration with thin liquids and mixed\n consistency barium boluses.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-11-15 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 848460, "text": " 9:35 AM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: look at rmca anatomy\n Admitting Diagnosis: STROKE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with rmca stroke.\n REASON FOR THIS EXAMINATION:\n look at rmca anatomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Look at right middle cerebral artery anatomy.\n\n NONCONTRAST HEAD CT:\n Exam compared to prior study of .\n\n FINDINGS:\n There is abnormal low density in the right hemisphere in the distribution of\n the right middle cerebral artery. This involves both and white matter,\n consistent with infarction. There is mild mass effect, slightly increased\n compared to yesterday's study. There is involvement of the basal ganglia on\n the caudate, consistent with the proximal M-1 portion of the middle cerebral\n artery involvement. There is no evidence of hemorrhage. There is no evidence\n of an extra-axial fluid collection.\n\n IMPRESSION: Evolution of right hemisphere abnormality consistent with middle\n cerebral artery territory infarction.\n\n CTA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES\n\n FINDINGS:\n There is dramatic improvement in the appearance of the M-1 portion of the\n right medial cerebral artery since the MRA study of . There is\n good visualization of the proximal portion of the M-1 portion. There is slight\n irregularity of the proximal portions of the anterior and posterior division\n M-2 branches with some diminished flow in the distal branches when compared to\n the left side. It is however dramatically improved compared to the MRA study.\n There is no evidence of aneurysm. The vertebrobasilar system is patent. The\n left middle cerebral artery system is likewise patent.\n\n IMPRESSION: Dramatic improvement in the right middle cerebral artery\n distribution arterial anatomy since the previous examination. There is some\n stenosis of the distal M-1 or proximal M-2 branches as described.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-11-13 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 848245, "text": " 3:42 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Please r/o acute stroke, AWAITING MRI FOR POTENTIAL INTERVEN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with left hemiplegia, now intubated for decreased respirations.\n Exam not helpful - on propofol. Ct with right sulci effacement possibly.\n REASON FOR THIS EXAMINATION:\n Please r/o acute stroke, AWAITING MRI FOR POTENTIAL INTERVENTION.\n ______________________________________________________________________________\n WET READ: JCCJ SUN 7:04 PM\n large area of abnormal diffusion within the right MCA territory with abnormal\n flair and T2 signal as well, consistent w/ infarction\n MRA shows abrupt cut-off of right MCA\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: Acute stroke with left hemiplegia. Now intubated for decreased\n respiration. On propofol. Right-sided sulcal effacement on CT.\n\n COMPARISON: No prior studies are available for comparison.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted MR of the brain with susceptibility\n and diffusion-weighting. 3D time-of-flight MR angiography of the circle of\n with multiplanar reformatted images.\n\n FINDINGS: There is a large area of increased T2 signal and increased FLAIR\n signal along the cortex of the right cerebral hemisphere, within the right\n middle cerebral artery territory, including the right caudate nucleus (artery\n of territory). This corresponds to a similar large area of abnormal\n signal on the diffusion- weighted images. There is slight mass effect within\n this area, although there is no shift of the normally midline structures.\n There is no hydrocephalus. Mucosal thickening is noted within the ethmoid\n sinuses bilaterally. No definite areas of abnormal susceptibility artifact\n are evident.\n\n MRA OF THE CIRCLE OF : There is abrupt cut-off of the right middle\n cerebral artery, approximately 1.5 cm distal to the take-off of the anterior\n cerebral artery. Flow signal within the remainder of the major branches of the\n circle of appears unremarkable. No aneurysm is evident.\n\n IMPRESSION: Large right middle cerebral artery territory infarction. Abrupt\n cut- off of the right middle cerebral artery M1 segment. approximately 1.5 cm\n distal to the right anterior cerebral artery take-off.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-11-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 848281, "text": " 12:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for edema, herniation. Requested per Dr. \n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with acute right hemisphere stroke.\n REASON FOR THIS EXAMINATION:\n Please evaluate for edema, herniation. Requested per Dr. to be done.\n PLEASE PERFORM AT MIDNIGHT on .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD\n\n INDICATION: Acute right hemispheric stroke, question edema, herniation.\n\n Comparison is made to the MRI scan performed on .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Consistent with the recent MRI scan there is a large area of\n hypodensity in the distribution of the right middle cerebral artery with loss\n of -white differentiation. There is no intraparenchymal or extraaxial\n hemorrhage appreciated. Note is made of some motion artifact. There is again\n demonstrated slight mass effect with asymmetry of the right lateral ventricle.\n There is no evidence of brain herniation. The ventricles, sulci and cisterns\n are unchanged in configuration. The visualized paranasal sinuses and osseous\n structures are unremarkable.\n\n IMPRESSION: Evolution of large right middle cerebral artery infarction with\n development of loss of -white differentiation and cytotoxic edema without\n evidence for herniation.\n\n" }, { "category": "Radiology", "chartdate": "2157-11-14 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 848369, "text": " 2:55 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: Etiology of stroke\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with R MCA stroke\n REASON FOR THIS EXAMINATION:\n Etiology of stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with recent stroke in the territory of the right\n middle cerebral artery.\n\n TECHNIQUE AND FINDINGS: Duplex ultrasonography was performed at the level of\n the cervical portions of the bilateral carotid and vertebral arteries.\n\n No plaque was detected. The waveforms and velocities in the bilateral\n internal, common and external carotid arteries were normal, as well as in the\n intertransverse portions of the bilateral vertebral arteries.\n\n CONCLUSION: Normal examination.\n\n" }, { "category": "Radiology", "chartdate": "2157-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 849074, "text": " 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p left subclavian central line placement, now spiking\n temps.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n PORTABLE CHEST: Comparison is made to prior study dated . The tip of\n the central line remains in the SVC. The cardiac and mediastinal contours are\n stable.\n\n There is minimal patchy increased density in the left retrocardiac area. This\n was also noted on a film of . This may reflect some residual\n atelectasis, although given the history of fever, early/limited pneumonia\n cannot be excluded. The lungs are otherwise clear. The lateral costophrenic\n angles are sharp without effusion. Residual oral contrast is present within\n the colon.\n\n IMPRESSION: Minimal patchy left retrocardiac density; cannot rule out\n pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2157-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848477, "text": " 11:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumonia\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p left subclavian central line placement\n\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central line placement, question pneumonia.\n\n AP UPRIGHT CHEST: Comparison to AP supine chest of . Left sided\n subclavian line, in the SVC, unchanged in position. The lungs are clear\n without evidence of consolidation or effusion. Heart size is within normal\n limits. The mediastinal and hilar contours are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary disease. No evidence of pneumonia or\n pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2157-11-13 00:00:00.000", "description": "Report", "row_id": 172358, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-15 00:00:00.000", "description": "Report", "row_id": 1460585, "text": "Pt. is 40 y.o. male admitted s/p rt. MCA stroke with lt. hemiplegia. Pt. is lethargic,arouses to voice, appropriate. C/o HA at 2100, relieved with Tylenol supp x1. Follows commands on the rt. side, strong hand squeez, lifts and holds rt. leg, min. movement of lt. leg noted, posturing of rt. arm. +PERRLA, intact cough, ? gag might be slightly impaired.\nResp: Received on OFM 50%, weaned to RA with sats 100%, rr 20s, LS clear, slightly diminished at bases. Nonporductie cough noted. Denies SOB.\nCV: HR 50s-70s, SB to NSR, no ectopy. ABP 150s-180s/80s-90s, continues on NEO gtt, titrated to keep SBP 160s-170s per neuro. lower that atretial: SBP 140s-160s. No peripheral edema noted.\nGI/GU: Abd. soft, nontender, +BS, no BM. Remains NPO, on IV NS at 100cc/hr. Needs swallow eval prior to feeding. Foley patent, lrg. amts of clear yellow urine out.\nEndo: Insulin gtt currently at 0.5u/hr, titrated scale.\nID: Tmax 101, medicated with TYlenol supp. Continues on IV Famotidine.\nSocial: No contact from family made overnight.\nAccess: A-line site bleeding noted pt. activley moving rt. arm, dsg. and entire setting changed.\nPlan head CT and Echo today. Continue frequent neuro checks.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-15 00:00:00.000", "description": "Report", "row_id": 1460586, "text": "micu 0700-1900 RN notes\n\nneuro: neuro assessment Q1H, arouse to voice, oriented x2, open eyes to spont, PERL 3mm/brisk. L eye deviates midline and not tracking surroundings. Moves R side to command strong hand grasp. LUE min movement, LUE Postural movement to stimulation, moves LLE minimal no change. @ 0930 done head CT-A, preliminary report: dramatic improvement from CT @ . speech/swallow eval: swallow limitation, able drink some water/ice chips, no food, plan: video swallow test @ . c/o R sided headache, recieved TYLENOL PR w/relief\n\nresp: Off O2, sat 98-100%, RR 14-22, LS clear, productive/ strong couhg.\n\ncv: HR 55-70 NSR/SB, no ectopy, d/c A-line d/t bleeding, 150-165, cont GTT IV NEO , titrate to goal SBP 140-160. CAROTID U/S normal findings, no stenosis. Cardiac ECHO - preliminary report: normal findings.\n\nid: afebrile, Tmax 99.8, WBC 21.2 up from 20.1 @ . CxR normal, sent urine culture. ?start ABX\n\nendo: cont IV INSULIN titrated to FSBS Q1H.\n\nGU/GI: Foley u/o autodiursis 60-350cc/hr. Abd soft nontender +BS no BM. NPO pending swallowing eval. start ice chips per eval and further studies .\n\nsocial: full code, family visites/updated, met w/team\n\nplan:wean NEO,titrate SBP 140-160\n cont neuro check Q1h\n video test for swallow eval\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-14 00:00:00.000", "description": "Report", "row_id": 1460581, "text": "Respiraotry Care:\nPatient received from the ED and was able to be transitioned from A/C to CPAP/PSV after CT scan at midnight. Morning abg results revealed a compensated respiratory acidemia with excellent oxygenation.\n\nRSBI = 47 on 0-PEEP and 5 cm PSV.\n\nRepeat CT scan in am, with a potential trip to the OR after.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-14 00:00:00.000", "description": "Report", "row_id": 1460582, "text": "NURSING PROGRESS NOTES -0700\nPLEASE SEE FHP FOR PRIOR HX AND OSH INFORMATION.\n\nPT ADMITTED TO MICU B FROM ED AT , W/ DX OF RIGHT MCA INFARCT. PT LETHARGIC PT TO VOICE. NEURO ASSESSMENTS PREFORMED Q 1HR AS ORDERED AND DOCUMENTED. OBTAINED MRI OF HEAD @1300 AND CT OF HEAD @0000 .\n\nNEURO: PT TO VOICE W/ EPISODES OF RESTLESSNESS ESP.W/ RIGHT LEG. NODS APPROPRIATELY TO YES/NO ANSWERS. PERL 4MM BRISK. RIGHT HAND HAS STRONG HG, RIGHT HAND POSTURES TO NOXIOUS STIMULI ONLY(NAIL BED PRESSURE), RIGHT LEG MOVES FREELY IN BED HE KICKS IT UP OFTEN, LEFT LEG HE MOVES W/ FLEXION W/DRAWAL AT FIRST ONLY W/ NOXIOUS STIMULI AS THE SHIFT PROGRESSED HE HAS MOVED IT MORE ON HIS OWN.IT IS STILL WEAKER THAN RIGHT LEG. DIPRIVAN GTT USED TO HELP W/ VENT ADAPTION GTT SHUT OFF TO PREFORM CHECKS AND THEN RESTARTED. AT PRESENT GTT AT 10MCQ/KG/MIN\n\nRESP: PT HAS ORAL #8 ETT 25CM AT LIP LINE, SUCTIONED THIN TAN SECRETIONS, MINIMAL FROM ETT. LS CLEAR, PT WAS ON AC ABGS 7.53/45/178/97% ON 50% FIO2 VENT SETTINGS CHANGED TO CPAP 5/5 40% FIO2 ABGS 7.37/46/167/28/98% PT 'S RATE 16\n\nCV: TELE SB-SR 52-80S HE HAS BEEN TACHYCARDIC WHEN AGITATED BEFORE BEING STARTED ON THE DIPRIVAN HE WAS 110 ST. SBP 160-180S TITRATING NEO GTT TO KEEP SBP 160-170S AT PRESENT RATE IS 2MCQS/KG/MIN HRT SNDS S1S2, PT HAS RIGHT RADIAL ALINE INTACT, LEFT SC TLCL, 3 PERIPH. SL (FROM OSH), PEDAL AND POST TIB PULSES ARE +4 PALP NO EDEMA.\n\nGI: PT HAS OGT TO LWS VERY MINIMAL NOTED TO BE RETURNING FROM OGT.\n\nGU: PT HAS FOLEY CATH DRAINING YELLOW URINE PLEASE SEE CAREVUE FOR Q1HR OUTPUTS.\n\nCOMFORT: CONT TO USE DIPRIVAN GTT FOR VENT ADAPTION\n\nSOCIAL: WIFE: AND HAS CHILDREN, PARENTS AND ONE BROTHER\n\nSKIN: INTACT:\n\nCODE: FULL\n\nENDO: INSULIN GTT AT 1UNIT/HR BS Q1HR PER PROTOCAL 150-101\n\nPLAN:\n1. CONT TO ASSESS NEURO STATUS Q1HR AND IF PT IS MORE SLEEPY/AND OR RIGHT HAND BECOMES WEAK AND OR ANY CHANGE IN RESPONSIVENESS CALL TEAM PT GO TO THE OR TO HAVE HEMICRANIECTOMY.\n\n2. CONT TO MAINTAIN COMFORT LEVEL AND ADEQUATE REST PERIODS TRY TO SPREAD OUT CARE THROUGHOUT SHIFT TO COINCIDE WITH NEURO CHECKS\n\n3. CONT TO TITRATE NEO GTT FOR A SBP OF 160-170\n\n4. CONT INSULIN GTT AND CHECK BS Q1HR SSC ALREADY ORDERED IF INSULIN GTT DC'D THIS AM\n\n5. CONT TO INFORM FAMILY OF PLAN OF CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-14 00:00:00.000", "description": "Report", "row_id": 1460583, "text": "Resp care\nPt remains on minimal vent support. No recent ABG's as of yet. BS coarse->clear, sx sm-mod thick yellow secretions. ? extubate in near future.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-14 00:00:00.000", "description": "Report", "row_id": 1460584, "text": "micu 0700-1900 rn notes\n\nneuro: Q1hr neuro checks, stared shift mildy sedated on PROPOFOL, off at 0800, arouse to voice, nodding head appropriately yes/no, orient x1, Moves RUE random strong grasp, LUE no purposeful movement/posture to stimulation, LLE minimal movement on bed, pupiles 3mm/3mm/brisk. @1700 extubated, alert, orientx2, able to talk voice raspy, cough strong/productive, gag reflex intact. During this shift no neuro changes.\n\nresp:0700-1700 intubated on CPAP vent mode, 40%/5peep/5PS, sat 100%, LS clear sx mod/yellow/thick secretions. @ 1700 extubated, on face tent 50%, sat 98-99%, LS clear.\n\ncv: HR 50-70, down to 48, NSR/SB, no ectopy. cont NEO 2mcg/kg/min, titrate to maintain SBP 160-170, BP 160-177. CAROTID U/S DONE. INR 1.1\n\nid: afebrile Tmax 99.7, pan culture pending.\n\ngi/gu: foley, u/o >60cc/hr, urine yellow/clear, cont NACL 100cc/hr. PT NPO\n\nendo: cont IV insulin 2u/hr, BS Q1hr\n\nsocial: full code, family visites, updates, met w/team\n\nplan: cont neuro assesmant Q1hr\n head CT tommorow\n ECHO to r/o endocarditis\n" }, { "category": "Nursing/other", "chartdate": "2157-11-18 00:00:00.000", "description": "Report", "row_id": 1460591, "text": "Neuro: pt alert and oriented. very restless at times; pt is a smoker felt some restlessness might be due to this . PERL rt arm and leg of normal strenth and sensorium. left arm is flaccid. pt shows neglect incouraged pt to lift and support L arm when moving. noted left arm regid with decelebrate motion. at this time pt said his L shoulder hurt pt was unaware that his l arm . pt was alert and oriented at this time PERL. answering question appropriates. discussed with DR did not feel it was a focal SZ but a spasm. Pt did say his shoulder hurt last night; TX with motrin. ambien 5mg given for sleep. with effect pt did sleep well initially difficult to arouse once arouse alert.\n\nENDO: insulin drip stopped on days lantus given at 11am . humolog scale ordered. pt takes lantus at 2300 normally give next dose 12/17 at 1700 then give at 2300. Bs initally high,. discussed BS with Dr . plan more frequent BS during initially time off IV insulin.initially BS > 200 tx with 8units then BS 58 tx with gingerale and gram crackers repeat BS 310 humolog order given while pt is npo. IV changed D5 at 100.\n\nLungs : clear throughout\n\n CV: NSR no VEA. temp 98-99 oral. LSC 3 lumen patent D51/2 @ 100 an hour. palp DP/PT. labs pending HCT 35.\nGI: ABD soft. BS present. no BS. npo after midnight for TEE. pt aware. no N/V . no BM.\n\nGU: yellow urine clear\n\nSkin: intact. turns self and with assistance as need.\n\nA stable.\nP frequent nuero checks, monitor for further spasm. monitor FS closely q 3-4 hour initially tx as indicated. give half the ordered humolog does while pt is NPO and continue IV with D5. note and tx labs as indicated.\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-16 00:00:00.000", "description": "Report", "row_id": 1460587, "text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: AAOx3, Moving R upper and lower extrem ok, L side he can move leg spont, but w/ much effort. L arm, he has moved it on the bed, but can't lift it. Sensation is very < in L extrems as well. Tongue deviates a bit to the L and drrop noted L side of mouth when he smiles. He has been moving himself about the bed all night trying to get comfortable. Strong cough, intact gag. Pupils 3mm/brisk.\n\nCV: HR=60s, NSR, no ectopy. SBP=140-160s, but titrating neo up and down between 1.5 and 2mcg/kg/min to maintatin BP in this range; currently it's at 2mcg. +periph pulses, extrems cool, no edema.\n\nResp: R/A w/ 02 at 97%, lungs clear bilat, great cough effort, non-productive. Requested n/p at tone point during the night for his headache; he said it helped the headache before, but he only kept it on for a short while.\n\nGI/GU: abd soft, +BS, no BM. NPO w/ only a few ice chips, but does cough w/ small sips. Video swallow study to be done today. Foley cath w/ clear yellow urine - 100-350cc/hr.\n\nAccess: PIVx1, Rsubcl TLC\n\nPain: Headache - med x1 w/ tylenol supp w/ mod relief. No other complaints of discomfort aside from not being able to get comfortable in the bed!\n\nEndo: Insulin gtt at 1.5 units/hr maintaining BP 100-110s. RISS to be started in am. Am labs pending\n\nSocial: Large attentive family\n\nID: afebrile, not on any antibx.\n\nPlan: Wean insulin gtt and start RISS when ordered. Maintain neo gtt for BP, wean when ordered per team. Monitor neuro/cardiac/resp status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-16 00:00:00.000", "description": "Report", "row_id": 1460588, "text": "micu 0700-1900 rn notes\n\nneuro: more alert, oriented x3, open eyes to speech most of the time, move more LUE,still posture LUE, strong grasp RA,moves RUE/RLE appropreate. c/o HA/restlessnes, recieved Tylenol, w/mod relief, start PRN PO IBUBROFEN/VICODIN.\n\nresp: RA ,off O2, sat 98-99%, LS clear.\n\ncv: HR 62-74, NSR ,no ectopy. SBP 147-162, titrate IV NEO to goal SBP 120-130. cont IV NACL 100cc/hr. plan: wean NEO ,replace w/IV fluid\n\ngu/gi: foley, u/o 60-150cc/hr. abd soft, + BS, no BM this shift. @ 0900 done video swallow test, pt able to drink thick fluid/soft diet, has to be upright position, start thick fluid, d/c NPO.\n\nendo: cont IV insulin, FSBS Q1-2hr,see carevue.\n\nsocial: full code, family visites/updates, met w/team. ON family meeting w/ Dr. @ 1400.\n\nplan: wean IV NEO, goal SBP 120-130\n cont soft/thick fluid\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-17 00:00:00.000", "description": "Report", "row_id": 1460589, "text": "Nursing Progress Note/TRANSFER NOTE 1900hours-0700:\n** Pt admitted to BIMDC on from hospital. As reported pt had been at home in usual state of health (reports did feel sick after being at party night before with N/V x 1 day) at 1030a in morning and at approx 10:40a-wife heard thud and found pt to be slumped over on kitchen floor-leaning to the left-was able to answer questions at that time and could apparently move everything; wife at that time ? hypoglycemia-when pt did not improve-called 911. At , found to have R MCA stroke-left sided paralysis-lethargic-intubated to maintain airway and transferred to BIMD. At BIMDC-MRI confirmedR MCA stroke, also noted to be hypotensive so central line placed at that time and NEO intitiated. Please see systems note and PMH below.\n\nPMH: IDDM, HTN, smoker ( ppd) + more since age 13, high cholesterol, retinopathy, heart murmur. NKDA\n\nNEURO: Able to answer all questions-speech slightly slurred ( as confirmed by brother who was at bedside for initial eval) but able to answer all question- A & O x3 and can hold a full convresation but appears sleepy. Can follow all commands with right side of body. Left side of body-neglect. Left upper arm seems to have posture type movements-and occasional spotaneous movement of left LE on bed but not upon command. Pt will say that he can move that side and thinks that he is-but no movement noted. PEARL and able to stick out tongue, move tongue side to side. Passed swallow study for thickened liquids-did not difficulty swallowing. Also, pt very restless on evening and throughout early part of night-pulls off leads and c/o not being comfortable and with bad headache x several days-requested pain med which was given with good effect.\n\nCARDIAC: NSR with HR 70-s-80's. NIBP in place-goal of SBP 120-130. Remains on NEO gtt and had to increase slightly due to BP below goal range -currently at 0.4mcg. Denies any cardiac related syptoms.\n\nRESP: RA, lungs clear, RR 16-24. Sats >94%; no issues.\n\n\nGI/GU: Abd soft, non-distended. C/o hunger on evenings-given thickened liquids, puddings-sitting upright-did not appear to have trouble. No BM, BS present. Foley in place, adequate UO at >35cc/hr, clear, yellow. Needs occasional reminder of foley in place-pt thinks he can get up and walk to toilet.\n\nID: Afebrile, WBC coming down. LR at 100cc/hr x 1 liter.\n\nENDO: on Insulin gtt per slide scale-variable (see carevue)\n\nPSYCHOSOCIAL: Pt with wife and children with numbers on board in room. Brother visited last night-updated on care.\n\nPLAN: Attempt titration off NEO, if pt transfer to floor. ? Rehab facility. Cont hemodynamic and neuro monitoring.\n\n**Pt is a full code\n\n** Left SC TLC in place\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-17 00:00:00.000", "description": "Report", "row_id": 1460590, "text": "nursing note: 7a-7p\nneuro- pt alert and oriented x3. L side neglect persists. perla. slightly slurred speech. oob to chair with help of pt/ot.\n\nresp- ls clear. ra sats >98% no distress.\n\ncv- hr 80-100 sr no ectopy. neo weaned off, sbp stable 120's. lr at 100cc/h.\n\ngi- abd soft +bs no stool. taking soft solids with thickened liquids. aspiration precautions maintained, explained and reinforced.\n\ngu- foley patent for adequate amounts of clear yellow urine.\n\nendo- pt given lantus at 11am, insulin gtt shut off at 1700. humalog coverage every 6 hours. pt normally takes lantus at bedtime so plan is to postpone tomorrows dose to the afternoon and to get saturdays dose at normal bedtime. pt needs to be npo after midnight for TEE tomorrow.\n\nsocial- wife, sister, and friends at bedside throughput day. updated by nursing and DR .\n\ndispo- full code. plan for transfer to 5 tonight.\n" } ]

[ { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349469, "text": "TITLE:\n Chief Complaint: Fever and HOTN\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 46 y.o. F w/ syndrom, s/p multiple bowel resections w/ short\n gut syndrome on chronic TPN, multiple recurrent line infections and\n vascular occlusions. Transferred for fever and HOTN, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n LINES D/C'D - temporary line placed\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n - Surgical evaluation for abdominal pain - non-surgical\n - discitis seen on lumbar spine imaging\n History obtained from Medical records, HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, better\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: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 65 (63 - 102) bpm\n BP: 104/57(74) {79/45(56) - 117/62(82)} mmHg\n RR: 13 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 2,187 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 2,187 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 759 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, ostomy in place, tender B/L LQ,\n no rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, pale\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): AAO x 3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 251 K/uL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: C.diff - negative x1\n BCx - pending\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION - Klebsiella bacteremia, possible\n sources include line infection, discitis\n - femoral line d/c'd yesterday\n - f/u repeat BCx, send surveillance BCx\n - continue linezolid for VRE UTI/meropenem for bacteremia\n - d/c PO vanco/flagyl, send repeat C.diff\n - continue IVF today, MAP >55-60\n - hold Celexa given linezolid\n #Abdominal pain - stable to mildly improved\n - serial exams\n - defer abdominal CT for now\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n - cont fentanyl patch\n ARF - resolved with IVF, likely pre-renal\n - f/u lytes/Cr\n # FEN -\n - PO trial of clears today\n - holding TPN while lines out\n ICU Care\n Nutrition:\n Comments: PO diet, holding TPN for now\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Comments: R Midline\n Prophylaxis:\n DVT: SQ UF Heparin\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: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349472, "text": "TITLE:\n Chief Complaint: Fever and HOTN\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 46 y.o. F w/ syndrom, s/p multiple bowel resections w/ short\n gut syndrome on chronic TPN, multiple recurrent line infections and\n vascular occlusions. Transferred for fever and HOTN, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n LINES D/C'D - temporary line placed\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n - Surgical evaluation for abdominal pain - non-surgical\n - progression of discitis seen on lumbar spine imaging\n History obtained from Medical records, HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, better\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: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 65 (63 - 102) bpm\n BP: 104/57(74) {79/45(56) - 117/62(82)} mmHg\n RR: 13 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 2,187 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 2,187 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 759 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, ostomy in place, tender B/L LQ,\n no rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, pale\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): AAO x 3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 251 K/uL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: C.diff - negative x1, 2 pending\n BCx\n pending & \n Assessment and Plan\n 46 yo with hx Gardners syndrome. Admited to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n SEPSIS - Klebsiella bacteremia, possible sources include line\n infection, discitis. Overnight BP and lactate improved, WBC trending\n down\n - femoral line d/c'd yesterday, temporary midline place at IR\n - f/u repeat BCx, send surveillance BCx\n - continue linezolid for VRE UTI & meropenem for bacteremia\n - d/c PO vanco/flagyl, send repeat C.diff today\n - continue IVF today, wean levophed as able to keep MAP >55-60, PRN\n boluses for SBP<85\n - hold Celexa given linezolid\n #Abdominal pain - stable to mildly improved, LFTs stable and w/u thus\n far unrevealing. Surgical evaluation appreciated.\n - serial exams today\n - defer abdominal CT for now, but low threshold if worsening exam\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n - cont fentanyl patch\n ARF improved with IVF, likely pre-renal\n - f/u lytes/Cr today, continue IVF as above\n # FEN -\n - PO trial of clears today\n - holding TPN while lines out\n ICU Care\n Nutrition:\n Comments: PO diet, holding TPN for now\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Comments: R Midline\n Prophylaxis:\n DVT: SQ UF Heparin\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: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2145-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349298, "text": "46 year old female with Syndrome. Pt has an ileostomy with\n excessive output on 9 leading to hypotension, and transferred to\n CVICU for BP control.\n Hypotension (not Shock)\n Assessment:\n 70/40, excessive output in colostomy, baseline SBP usually 80,\n mentating WNL\n Action:\n 1 liter LR infusing wide open\n Response:\n BP 72/42\n Plan:\n BP control?? Pressors, line placement\n" }, { "category": "Physician ", "chartdate": "2145-09-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 349299, "text": "Chief Complaint: hypotension/sepsis\n HPI:\n Ms is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. SHe initially went to an\n OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI and was transferred here and put on Linezolid and\n Zosyn. MICU was called to eval for hypotension 60/pal on the floor.\n Patient has had increased ostomy outout, decreased urine output. She\n has been mentating faily well. Multiple attempts at EJ were done on\n the floor and she was transferred here for hypotension in the setting\n of limited access.\n Since admission she has been continued on Zosyn for the Klebsiella and\n Linezolid was added for the VRE in urine and Coag negative Staph\n bacteremia. She reports intermitted sharp nonradiating lower\n abdominal/back pain pain for the past several days. She reports\n decreased PO intake with associated nausea. She denies vomiting. She\n denies fevers or chills over the past several days, but hasn\nt been\n feeling well.\n Of note, she has been seen by IR who knows her well and they are\n concerned they have run out of access sites. Sh ehas had extensive\n venous occlusions with repeat stenting including right internal jugular\n vein, right brachiocephalic vein, IVC, right femoral and common\n iliacs. She does report decreased\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDICATIONS\n Past medical history:\n Family history:\n Social History:\n 1. syndrome\n - diagnosed at age 23\n - s/p colectomy ()\n - repeated small bowel resections persistent polyp growth\n - short gut syndrome and on chronic TPN since \n 2. s/p dermoid cyst removal, originally in small bowel, then extended\n to ovaries\n 3. Fibromyalgia\n 4. Osteoporosis\n 5. History of fungemia- parapsilosis , non-albicans\n , \n 6. History of staph epi sepsis\n 7. Mutliple venous occlusions: recanalized and stented the right\n internal jugular vein, right brachiocephalic vein, which however has\n occluded because of poor inflow reconstructed now the inferior vena\n cava with kissing stent\n extensions into the high inferior vena cava. A long-term right femoral\n access which had been available also had scar-down and during her last\n admission in actually required stenting even of the right\n femoral and external iliac vein.\n 8. History of GI bleed\n 9. Scoliosis s/p repair\n 10. s/p bilateral hip fracture and ORIF\n 11. s/p TAH BSO\n 12. s/p \n Father with syndrome as do 6 of 8 siblings. Father also with\n pancreatitis; died at 42 from polyp blocking pancreatic duct. Diagnosed\n when sister was going to the marines, then had testing given her\n father's dx's and diagnosed w/ Gardners. Mother and relatives with HTN\n and resulting CVA. Sister with breast ca\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: Parenteral nutrition\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 88 (88 - 88) bpm\n BP: 70/40(53) {70/40(53) - 70/40(53)} mmHg\n RR: 18 (18 - 18) insp/min\n Total In:\n 175 mL\n PO:\n TF:\n IVF:\n 175 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 175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Physical Examination\n General Appearance: Thin, jovial\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\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: Tender: , midline abdominal\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 470\n 11.1\n 82\n 0.6\n 5\n 23\n 103\n 3.4\n 139\n 34.9\n 7.3\n [image002.jpg]\n Fluid analysis / Other labs: Sed Rate: 44\n CRP: 13.8\n Imaging: TTE (Complete) Done at 2:53:44 PM FINAL\n The left atrium is normal in size. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n 60-70%). There is no ventricular septal defect. The right ventricular\n cavity is dilated with normal free wall contractility. The aortic valve\n leaflets (3) appear structurally normal with good leaflet excursion and\n no aortic regurgitation. No masses or vegetations are seen on the\n aortic valve. The mitral valve appears structurally normal with trivial\n mitral regurgitation. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. The estimated pulmonary artery\n systolic pressure is normal. No vegetation/mass is seen on the pulmonic\n valve. There is no pericardial effusion.\n ABDOMEN U.S. (COMPLETE STUDY) Study Date of 8:46 AM\n IMPRESSION:\n 1. No fluid collections identified. No findings to suggest an abscess.\n 2. Mild splenomegaly.\n 3. Common hepatic duct at the upper limits of normal measuring 1.0 cm.\n No intrahepatic biliary dilatation seen. Correlation with LFTs is\n recommended.\n OSH CT abdomen without contrast: Per ER reports no abscess found, no\n hydronephrosis.\n Microbiology: Blood cx : NGTD\n OSH:\n ===\n Ucx ->100,000Klebsiella (R to amp, cipro, levo, bactrim, S to\n cefazolin, gentamicin, zosyn) and >100,000 VRE (amp and vanco\n resistant)\n Blood cx - Klebsiella pneumoniae to cefazolin, gent,\n zosyn and levo) CoNS\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections now with\n limited access and Klebsiella, CoNS bactermia and Klebsiella UTI and\n hypotension on Linezolid and ZOsyn\n .\n Plan:\n =====\n Hypotension: could be due to increased ostomy output vs septic shock.\n Not going for septic shock is lack of hypo/hyperthermia, lack of\n leuckocytosis, lack of tachypnea or tachycardia. Also, per report OSH\n CT Abdomen negative, abdominal US negative for abscess here. Also\n surveillance BCx have been negative here. Of note, patient does have a\n history of line associated fungemia.\n - Will bolus with LR via tunnelled Hickman\n - Will use peripheral Levo as needed, per report from patient,\n baseline BP is 80\n - Will continue Linezolid/Zosyn\n - Cortisol in am\n - Will discuss empiric Fungal coverage on rounds.\n - Line when stable via IR\n - Image when stable\n - culture ostomy output\n .\n Klebsiella bacteremia/UTI:\n - Continue Linezolid/Zosyn\n - Appreciate ID recs\n ICU Care\n Nutrition: TPN\n Glycemic Control: Insulin in TPN\n Lines:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2145-09-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 349306, "text": "Chief Complaint: hypotension/sepsis\n HPI:\n Ms is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. SHe initially went to an\n OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI and was transferred here and put on Linezolid and\n Zosyn. MICU was called to eval for hypotension 60/pal on the floor.\n Patient has had increased ostomy outout, decreased urine output. She\n has been mentating faily well. Multiple attempts at EJ were done on\n the floor and she was transferred here for hypotension in the setting\n of limited access.\n Since admission she has been continued on Zosyn for the Klebsiella and\n Linezolid was added for the VRE in urine and Coag negative Staph\n bacteremia. She reports intermitted sharp nonradiating lower\n abdominal/back pain pain for the past several days. She reports\n decreased PO intake with associated nausea. She denies vomiting. She\n denies fevers or chills over the past several days, but hasn\nt been\n feeling well.\n Of note, she has been seen by IR who knows her well and they are\n concerned they have run out of access sites. Sh ehas had extensive\n venous occlusions with repeat stenting including right internal jugular\n vein, right brachiocephalic vein, IVC, right femoral and common\n iliacs. She does report decreased\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDICATIONS\n Past medical history:\n Family history:\n Social History:\n 1. syndrome\n - diagnosed at age 23\n - s/p colectomy ()\n - repeated small bowel resections persistent polyp growth\n - short gut syndrome and on chronic TPN since \n 2. s/p dermoid cyst removal, originally in small bowel, then extended\n to ovaries\n 3. Fibromyalgia\n 4. Osteoporosis\n 5. History of fungemia- parapsilosis , non-albicans\n , \n 6. History of staph epi sepsis\n 7. Mutliple venous occlusions: recanalized and stented the right\n internal jugular vein, right brachiocephalic vein, which however has\n occluded because of poor inflow reconstructed now the inferior vena\n cava with kissing stent\n extensions into the high inferior vena cava. A long-term right femoral\n access which had been available also had scar-down and during her last\n admission in actually required stenting even of the right\n femoral and external iliac vein.\n 8. History of GI bleed\n 9. Scoliosis s/p repair\n 10. s/p bilateral hip fracture and ORIF\n 11. s/p TAH BSO\n 12. s/p \n Father with syndrome as do 6 of 8 siblings. Father also with\n pancreatitis; died at 42 from polyp blocking pancreatic duct. Diagnosed\n when sister was going to the marines, then had testing given her\n father's dx's and diagnosed w/ Gardners. Mother and relatives with HTN\n and resulting CVA. Sister with breast ca\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: Parenteral nutrition\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 88 (88 - 88) bpm\n BP: 70/40(53) {70/40(53) - 70/40(53)} mmHg\n RR: 18 (18 - 18) insp/min\n Total In:\n 175 mL\n PO:\n TF:\n IVF:\n 175 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 175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Physical Examination\n General Appearance: Thin, jovial\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\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: Tender: , midline abdominal\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 470\n 11.1\n 82\n 0.6\n 5\n 23\n 103\n 3.4\n 139\n 34.9\n 7.3\n [image002.jpg]\n Fluid analysis / Other labs: Sed Rate: 44\n CRP: 13.8\n Imaging: TTE (Complete) Done at 2:53:44 PM FINAL\n The left atrium is normal in size. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n 60-70%). There is no ventricular septal defect. The right ventricular\n cavity is dilated with normal free wall contractility. The aortic valve\n leaflets (3) appear structurally normal with good leaflet excursion and\n no aortic regurgitation. No masses or vegetations are seen on the\n aortic valve. The mitral valve appears structurally normal with trivial\n mitral regurgitation. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. The estimated pulmonary artery\n systolic pressure is normal. No vegetation/mass is seen on the pulmonic\n valve. There is no pericardial effusion.\n ABDOMEN U.S. (COMPLETE STUDY) Study Date of 8:46 AM\n IMPRESSION:\n 1. No fluid collections identified. No findings to suggest an abscess.\n 2. Mild splenomegaly.\n 3. Common hepatic duct at the upper limits of normal measuring 1.0 cm.\n No intrahepatic biliary dilatation seen. Correlation with LFTs is\n recommended.\n OSH CT abdomen without contrast: Per ER reports no abscess found, no\n hydronephrosis.\n Microbiology: Blood cx : NGTD\n OSH:\n ===\n Ucx ->100,000Klebsiella (R to amp, cipro, levo, bactrim, S to\n cefazolin, gentamicin, zosyn) and >100,000 VRE (amp and vanco\n resistant)\n Blood cx - Klebsiella pneumoniae to cefazolin, gent,\n zosyn and levo) CoNS\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections now with\n limited access and Klebsiella, CoNS bactermia and Klebsiella UTI and\n hypotension on Linezolid and ZOsyn\n .\n Plan:\n =====\n Hypotension: could be due to increased ostomy output vs septic shock.\n Not going for septic shock is lack of hypo/hyperthermia, lack of\n leuckocytosis, lack of tachypnea or tachycardia. Also, per report OSH\n CT Abdomen negative, abdominal US negative for abscess here. Also\n surveillance BCx have been negative here. Of note, patient does have a\n history of line associated fungemia.\n - Will bolus with LR via tunnelled Hickman\n - Will use peripheral Levo as needed, per report from patient,\n baseline BP is 80\n - Will continue Linezolid/Zosyn\n - Cortisol in am\n - Will discuss empiric Fungal coverage on rounds.\n - Line when stable via IR\n - Image when stable\n - culture ostomy output\n .\n Klebsiella bacteremia/UTI:\n - Continue Linezolid/Zosyn\n - Appreciate ID recs\n ICU Care\n Nutrition: TPN\n Glycemic Control: Insulin in TPN\n Lines:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n This note was drafted prior to her WBC count returning. Given this new\n leuckocytosis of 57K, she is likely septic at this point. Her CT back\n looks like discitis/osteomyelitis @ L4-5. Will recheck CBC to validate\n this CBC.\n Of note, Positive culture from OSH on positive for Klebsiella.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:59 ------\n" }, { "category": "Physician ", "chartdate": "2145-09-24 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 349314, "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 46 yo with hx Gardners syndrome. Admiteed to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n Patient admitted from: \n History obtained from Patient, H\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\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 Colectomy 85, multiple SBO with muliple Bowel resections\n Short gut syndrome\n TPN (via indwelling line with multiple infections): Klebsiella\n bactermia (Cefaz). TPN since \n - fungemia\n - staph epi sepsis\n extensive venous occlusions with stents: right IJ, right\n brachiocephalic, IVC stents,\n Hx of GIB\n B/l hip fractures s/p ORIF\n s/p TAH and BSO\n 6 sibs with gardners syndrome (as did dad)\n Occupation:\n Drugs: none\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Gastrointestinal: Abdominal pain, Nausea\n Flowsheet Data as of 09:15 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 88 (88 - 88) bpm\n BP: 70/40(53) {70/40(53) - 70/40(53)} mmHg\n RR: 18 (18 - 18) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n PO:\n TF:\n IVF:\n 525 mL\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 484 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\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: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, ostomy mid\n abdomen. Green out put.\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 332 K/uL\n 29.2 %\n 9.2 g/dL\n 86 mg/dL\n 1.4 mg/dL (0.6)\n 9 mg/dL\n 20 mEq/L\n 107 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 57.0 K/uL\n [image002.jpg]\n 06:45 AM\n WBC\n 57.0\n Hct\n 29.2 (34)\n Plt\n 332 (470)\n Cr\n 1.4\n Glucose\n 86\n Other labs: PT / PTT / INR:15.3/39.4/1.4, ALT / AST:33/29, Alk Phos / T\n Bili:421/0.4, LDH:158 IU/L, Ca++:7.0 mg/dL, Mg++:0.8 mg/dL, PO4:3.4\n mg/dL\n Imaging: Abd US : no abscess\n TTE : EF 60-70% no Veg.\n CXR :\n CT L spine (I-) : L4-5 discitis/osteo\n Microbiology: Blood clx : NGTD\n : NGTD\n c. dif (pending) : pending\n Assessment and Plan\n 46 yo with hx Gardners syndrome. Admited to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n >Hypotension/Sepsis: concern for multiple sources including line (which\n was last changed here in and has been treated through at\n least one line infection), also with rapid rise in WBC and ostomy\n output is concerning for c. dif given recent antibiosis, current abx\n include:\n Linezolid\n Pip-Tazo\n Flagyl PO (she is not taking)\n - Will continue : Linezolid and Pip-Tazo\n and Add:\n - Vanco PO\n - Flagyl IV\n to cover c.dif. we will image CT abd with PO contrast (no I contrast).\n Surgery Consult today.\n -Call IR to remove and replace line\n -Follow up with ID re: empiric coverage for fungal pathogens (check 1,3\n glucan, galactomannan)\n - At some point will need to have ortho see her\n - Check lactate now and fluid resusc with goal MAP > 60 mmHg.Has\n received about 3L and will need to Fluid bolus with LR. Will use NE as\n first pressor.\n - defer steroids given concern for c. dif\n - check amylase and lipase ? pancreatitis\n >Electrolytes: replete as needed and check 4-6hrs today, Defer TPN\n >Renal failure: likely pre-renal. Check urine lytes. Will cont to vol\n resus with LR bolus\n Other issues\n ICU Care\n Nutrition:\n Comments: defer TPN\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Comments:\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: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349818, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Significant Events : *** Lasix 20 Mg IV X1 given with good response,\n Goal neg 1 lit.\n **** sitting up @ chair for \n hrs , tolerated well.\n ****PA/ Lat CXR .\n **** call out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 4 l nasal cannula. Sat dropped to high 80\ns when @\n chair. Lungs diminished at base bilat & clear at upper lobes.\n Action:\n Using IS when she is awake./ sitting up. CXR PA/ Lat at 1500\n hrs. Lasix 20 mg IV X1 given.\n Response:\n Satting 90-93% mostly. UO good.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often. Plan to check PM\n lytes, awaiting result.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have abd pain. IV dilaudid 0.25 mg q3 prn. Fentanyl patch @\n RUA (placed on ), Lidocaine patch at lower back ( at 0800\n hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/ dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349794, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Significant Events : *** Lasix 20 Mg IV X1 given with good response,\n Goal neg 1 lit.\n **** sitting up @ chair for \n hrs , tolerated well.\n ****PA/ Lat CXR .\n **** ? Possible call out\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 4 l nasal cannula. Sat dropped to high 80\ns when @\n chair. Lungs diminished at base bilat & clear at upper lobes.\n Action:\n Using IS when she is awake./ sitting up. CXR PA/ Lat at 1500\n hrs. Lasix 20 mg IV X1 given.\n Response:\n Satting 90-93% mostly. UO good.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often. Plan to check PM\n lytes, awaiting result.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have abd pain. IV dilaudid 0.25 mg q3 prn. Fentanyl patch @\n RUA (placed on ), Lidocaine patch at lower back ( at 0800\n hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/ dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349806, "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 BLOOD CULTURED - At 02:48 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n diffusely (but less then previous exam)\n Extremities: Right: 1+, Left: 1+\n Neurologic: Attentive, Responds to: verbal stimuli. Moving all ext.\n Labs / Radiology\n 9.2 g/dL\n 269 K/uL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI and resultant septic shock.\n SEPSIS - likely line sepsis, line removed with + blood clx\n (Kleb pneumo pip- ), WBC trending down and afebrile with\n subsequent neg clx ( and ). Concern remains for chronic but\n worsening discitis (concerning for source of repeated infection: osteo)\n - continues on meropenem (Day 3), will change back to Pip- for 14\n day course.\n - continues on linezolid for UTI, last day today. (7 day course)`\n - needs f/u w/ ortho for discitis once acute issues are resolved: may\n need bx of L4-5\n - ID following appreciate input.\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic, now\n SBP near 100 mmHg\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal 1L out with lasix prn\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - check PA and lateral CXR to eval RLL effusion and LLL collapse\n - chest PT, OOB to chair, incentive spirometry for LLL atelectasis\n - goal net neg 1L\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO (will need new TPN at some point)\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349622, "text": "TITLE:\n Chief Complaint: HOTN, abdominal pain\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 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n 24 Hour Events:\n Flagyl and PO vanco stopped after C.diff negative\n Diet advanced\n BCx from - GNRs 2/4 bottles\n New O2 requirement today\n 4L O2 to maintain sat ~90%\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Meropenem - 06:05 AM\n Linezolid - 07:57 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:58 AM\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Other medications:\n Lidoderm, fent patch,\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 Constitutional: Fatigue\n Pain: Mild\n Pain location: abdomen, unchanged\n Flowsheet Data as of 08:56 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: 36.4\nC (97.6\n HR: 73 (69 - 79) bpm\n BP: 92/52(67) {80/48(60) - 102/78(245)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 2,363 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 2,363 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 1,213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, chronically ill\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : ,\n Diminished: B/L bases)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 230 K/uL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - very suboptimal film, rotated\n New R effusion, ? LLL atelectasis/collapse\n Microbiology: BCx () - GNR\n BCx () - pending\n C.diff (-) x3\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n SEPSIS - likely line sepsis, line removed , WBC trending down,\n Afebrile, chronic but worsening discitis\n - continues on meropenem (Day 3)\n - continues on linezolid for UTI (today day 6 of 7)\n - f/u surveillance cultures, f/u speciation/sensitivities of BCx\n GNRs\n - needs f/u w/ ortho for discitis once acute issues are resolved\n - ID following\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal even today\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - chest PT, OOB to chair, incentive spirometry for LLL collapse\n ICU Care\n Nutrition:\n PO intake, ultimately will need to resume TPN when acute infectious\n issues resolved\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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: 25 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349625, "text": "TITLE:\n Chief Complaint: HOTN, abdominal pain\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 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n 24 Hour Events:\n Flagyl and PO vanco stopped after C.diff negative\n Diet advanced\n BCx from - GNRs 2/4 bottles\n New O2 requirement today\n 4L O2 to maintain sat ~90%\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Meropenem - 06:05 AM\n Linezolid - 07:57 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:58 AM\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Other medications:\n Lidoderm, fent patch,\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 Constitutional: Fatigue\n Pain: Mild\n Pain location: abdomen, unchanged\n Flowsheet Data as of 08:56 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: 36.4\nC (97.6\n HR: 73 (69 - 79) bpm\n BP: 92/52(67) {80/48(60) - 102/78(245)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 2,363 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 2,363 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 1,213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, chronically ill\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : ,\n Diminished: B/L bases)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 230 K/uL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - very suboptimal film, rotated\n New R effusion, ? LLL atelectasis/collapse\n Microbiology: BCx () - GNR\n BCx () - pending\n C.diff (-) x3\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n SEPSIS - likely line sepsis, line removed , WBC trending down,\n Afebrile, chronic but worsening discitis\n - continues on meropenem (Day 3)\n - continues on linezolid for UTI (today day 6 of 7)\n - f/u surveillance cultures, f/u speciation/sensitivities of BCx\n GNRs\n - needs f/u w/ ortho for discitis once acute issues are resolved\n - ID following\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal even today\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - chest PT, OOB to chair, incentive spirometry for LLL collapse\n ICU Care\n Nutrition:\n PO intake, ultimately will need to resume TPN when acute infectious\n issues resolved\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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": "2145-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349702, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n Pt received 2 lumen picc in IR . BP now improved.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 88-94% on 5 l nasal cannula. l/s dim.\n Action:\n Enc use of IS. Ivf now off.\n Response:\n Sats up to 90-93% for the most part\n Plan:\n Titrate o2 as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have situational abd pain. IV dilaudid q3 prn\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain improved w/dilaudid. Also with fent patch and lidocaine patch qd.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349609, "text": "TITLE:\n Chief Complaint: HOTN, abdominal pain\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 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n 24 Hour Events:\n Flagyl and PO vanco stopped after C.diff negative\n Diet advanced\n BCx from - GNRs 2/4 bottles\n New O2 requirement today\n 4L O2 to maintain sat ~90%\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Meropenem - 06:05 AM\n Linezolid - 07:57 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:58 AM\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Other medications:\n Lidoderm, fent patch,\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 Constitutional: Fatigue\n Pain: Mild\n Pain location: abdomen, unchanged\n Flowsheet Data as of 08:56 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: 36.4\nC (97.6\n HR: 73 (69 - 79) bpm\n BP: 92/52(67) {80/48(60) - 102/78(245)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 2,363 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 2,363 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 1,213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, chronically ill\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : ,\n Diminished: B/L bases)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 230 K/uL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - very suboptimal film, rotated\n New R effusion, ? LLL atelectasis/collapse\n Microbiology: BCx () - GNR\n BCx () - pending\n C.diff (-) x3\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n SEPSIS - likely line sepsis, line removed , WBC trending down,\n Afebrile\n - continues on meropenem (Day 3)\n - continues on linezolid for UTI (today day 6 of 7)\n - f/u surveillance cultures, f/u speciation/sensitivities of BCx\n GNRs\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal even today\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - chest PT, OOB to chair, incentive spirometry for LLL collapse\n ICU Care\n Nutrition:\n PO intake, ultimately will need to resume TPN when acute infectious\n issues resolved\n Glycemic Control: SSI\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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: 25 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349629, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Consistently decreased sats down to 88 despite increase in O2. LS with\n faint crackles. Denies SOB. CXR showing small collapse on left.\n Action:\n IVF stopped. Incentive spirometry in use.\n Response:\n Slight improvement in sats. Now > 90%\n Plan:\n Encourage use of incentive spirometry; encourage mobilization as\n tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain; abdominal pain (situational this admission).\n Action:\n Fentanyl patch; lidocaine patch for back pain; dilaudid IVP for acute\n abdominal pain.\n Response:\n Desired effect from Dilaudid. Does not stop pain but definite decrease\n to tolerable level.\n Plan:\n Continue with prescribed regimen.\n Sepsis without organ dysfunction\n Assessment:\n Positive bld cx from for gram negative rods. Also being treated\n for VRE in urine.\n Action:\n Linezolid for VRE; Meropenem for gram neg rods.\n Response:\n Pnd.\n Plan:\n Linezolid for total of 7 days, completed tomorrow. Continue with\n surveillance cultures.\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349792, "text": "Chief Complaint:\n 24 Hour Events:\n - GNR zosyn sensitive, can change back to zosyn vs more narrow abx\n - surv cx from ngtd ngtd\n - WBC trending back down to 8 from 12\n - cxr still with some rll atalectasis\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%, 3L\n ABG: ///22/\n Physical Examination\n NAD, A/Ox3, cn 2-12 grossly intact, elevated RIJ to level of ear, mild\n crackle at R base, bronchovesicular breath sounds on R, decreased\n breath sounds on L, no LE edema, abd soft non-tender. R mid line in\n place, no erythema, R a line, no erythema\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 269 K/uL\n 9.2 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n \n klebsiella pneumonia, pan sensitive, save bactrim\n Cdiff (-) x2\n Assessment and Plan\n 46 syndrome s/p small and large bowel resection on\n chronic TPN and hx of multiple line infections s/p femoral line\n removal, now being treated for OSH UTI and GNR Bacteremia.\n # leukocytosis/fever - +bacteremia at OSH (k. pna, coag(-) staph) and\n now growing K. pna from from blood here. Also had +uti-VRE at\n OSH, started on linezolid (D#7 ). CT performed on admit showed\n concern for osteomyelitis, discitis. ID has been following.\n - stop meropenem, initiate zosyn\n pan sensitive micrbobe, but\n given discitis with presumed but unknown microbe, will opt for broader\n coverage\n - continue linezolid indefinitely, initial plan for 7 days,\n pending ID recs\n - ultimately, likely will need IR-guided biopsy of discitis\n given CT findings and now recurrent bacteremia, but pending further\n stabilization of hemodynamics (borderline low BPs)\n -\n # hypotension\n initially, likely from septic shock, now with\n appropriate microbial coverage. Pt with baseline low BPs\n - will diureses, as below , with monitor of BP\n # hypoxia\n CXR showing R-sided fluid overload vs effusion, JVP\n elevated, large IVF administration over past 3 days, overall likely\n fluid overloaded.\n - diurese 1\n 1.5L (-), wean O2, monitor BP\n # access\n R-midline, will need more permanent placement, perhaps\n trans-hepatic venous access.\n PPI, HEP sq, OOB\n C/O pending stable hemodynamics post-diuresis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 349855, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Significant Events : *** Lasix 20 Mg IV X1 given with good response,\n Goal neg 1 lit.\n **** sitting up @ chair for \n hrs , tolerated well.\n ****PA/ Lat CXR .\n **** call out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 4 l nasal cannula. Sat dropped to high 80\ns when @\n chair. Lungs diminished at base bilat & clear at upper lobes.\n Action:\n Using IS when she is awake./ sitting up. CXR PA/ Lat at 1500\n hrs. Lasix 20 mg IV X1 given.\n Response:\n Satting 90-93% mostly. UO good.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often. Plan to check PM\n lytes, awaiting result.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have abd pain. IV dilaudid 0.25 mg q3 prn. Fentanyl patch @\n RUA (placed on ), Lidocaine patch at lower back ( at 0800\n hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/ dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n Demographics\n Attending MD:\n \n Admit diagnosis:\n GARDNERS SYNDROME\n Code status:\n Height:\n Admission weight:\n 40 kg\n Daily weight:\n Allergies/Reactions:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Precautions: Contact\n PMH: GI Bleed\n CV-PMH:\n Additional history: syndrome dx at age 23, s/p colectomy\n (), multiple small bowel resections persistent polyp growth,\n short gut syndrome on chronic TPN since , s/p dermoid cyst removal\n (originally in small bowel, then extended to ovaries), fibromyalgia,\n osteoporosis, history of fungemia ( parapsilosis ,\n non-albicans , ), history of staph epi sepsis, GI\n bleed, scoliosis s/p repair, s/p bilateral hip fracture and ORIF, s/p\n TAH BSO, s/p CCY, mutliple venous occlusions: recanalized and stented\n the right internal jugular vein, right brachiocephalic vein, which\n however has occluded because of poor inflow reconstructed now the\n inferior vena cava with kissing stent extensions into the high inferior\n vena cava. A long-term right femoral access which had been available\n also had scar-down and during her last admission in actually\n required stenting even of the right femoral and external iliac vein.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:60\n Temperature:\n 97.7\n Arterial BP:\n S:110\n D:58\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 2,054 mL\n 24h total out:\n 3,980 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:10 PM\n Potassium:\n 3.4 mEq/L\n 04:10 PM\n Chloride:\n 107 mEq/L\n 04:10 PM\n CO2:\n 27 mEq/L\n 04:10 PM\n BUN:\n 6 mg/dL\n 04:10 PM\n Creatinine:\n 0.9 mg/dL\n 04:10 PM\n Glucose:\n 106 mg/dL\n 04:10 PM\n Hematocrit:\n 28.5 %\n 04:12 AM\n Finger Stick Glucose:\n 103\n 06:37 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 7\n Transferred to: cc717\n Date & time of Transfer: 2230\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349762, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 5 l nasal cannula. Lungs diminished at base bilat &\n clear at upper lobes.\n Action:\n Using IS when she is awake.\n Response:\n Satting 90-93% mostly.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have situational abd pain. IV dilaudid 0.25 mg q3 prn.\n Fentanyl patch @ RUA (placed on ), Lidocaine patch at lower back\n ( at 0800 hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349778, "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 BLOOD CULTURED - At 02:48 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\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), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n diffusely\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 269 K/uL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n SEPSIS - likely line sepsis, line removed with + blood clx (GNR\n spp pending pip- ), WBC trending down, Afebrile, chronic but\n worsening discitis (concerning for source of repeated infection: osteo)\n - continues on meropenem (Day 3), will change back to Pip- for 14\n day course.\n - continues on linezolid for UTI, last day today.\n - f/u surveillance cultures, f/u speciation/sensitivities of BCx\n GNRs\n - needs f/u w/ ortho for discitis once acute issues are resolved: may\n need bx of L4-5\n - ID following appreciate input.\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal 1L out.\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - check PA and lateral CXR to eval RLL effusion.\n - chest PT, OOB to chair, incentive spirometry for LLL collapse\n - goal net neg 500 cc.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO (will need new TPN at some point)\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349845, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Significant Events : *** Lasix 20 Mg IV X1 given with good response,\n Goal neg 1 lit.\n **** sitting up @ chair for \n hrs , tolerated well.\n ****PA/ Lat CXR .\n **** call out today.\n *** 40 KCL in 500 ml NS started\n @ 125 ml/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 4 l nasal cannula. Sat dropped to high 80\ns when @\n chair. Lungs diminished at base bilat & clear at upper lobes.\n Action:\n Using IS when she is awake./ sitting up. CXR PA/ Lat at 1500\n hrs. Lasix 20 mg IV X1 given.\n Response:\n Satting 90-93% mostly. UO good.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often. Plan to check PM\n lytes, awaiting result.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have abd pain. IV dilaudid 0.25 mg q3 prn. Fentanyl patch @\n RUA (placed on ), Lidocaine patch at lower back ( at 0800\n hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/ dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Nursing", "chartdate": "2145-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349507, "text": "Hypotension (not Shock)\n Assessment:\n BPs in 110s beginning of shift.\n Action:\n Turned Levophed gtt off. BP stable for ~1.5hrs but decreased to\n 70s-80s. Gave fluid bolus 1Liter LR.\n Response:\n Responsive to fluid bolus with increase to 80s-90s. Patient\ns baseline\n BP 80s.\n Plan:\n Fluid boluses as required.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain which started in . Also has abdominal pain\n especially on palpation.\n Action:\n Lidocaine patch on lower back. Receiving Dilaudid 0.25mcg.\n Response:\n Desired effect with Dilaudid.\n Plan:\n Lidocaine patch off at ; Diluadid IVP Q3 hrs prn.\n Sepsis without organ dysfunction\n Assessment:\n Gram neg rods both bottles from .\n Action:\n Receiving Meropenem on sched. Additional bld cx sent from Midline\n today.\n Response:\n PND.\n Plan:\n Follow culture data and send surveillance cultures as ordered;\n Meropenem as scheduled.\n" }, { "category": "Nursing", "chartdate": "2145-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349389, "text": "TITLE:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o back pain/abdominal pain throughout shift .\n Action:\n Pt repositioned, given backrub, and pt given dilaudid 0.25mg IV q3h.\n Response:\n Pt resting comfortably after interventions.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n Hypotension (not Shock)\n Assessment:\n Pt with SBP 70\ns-90\ns throughout the shift.\n Action:\n Pt given numerous fluid boluses, A-line placed, and pt started on\n levophed drip.\n Response:\n Pt with SBP 90\ns and MAP\ns >65.\n Plan:\n Keep MAP\ns >65 and continue fluid/levophed drip.\n Sepsis without organ dysfunction\n Assessment:\n Pt afebrile at this time and WBC 30\ns-40\n Action:\n Pt given fluid and started on multiple antibiotics. 1 set of blood\n cultures also sent.\n Response:\n Pt with no temp at this time.\n Plan:\n Continue to check CBC and temp and administer antibiotics.\n Pt also taken down to IR by anesthesia for midline placement. Hickman\n in left groin taken out in IR and midline placed in right upper arm.\n No complications at this present time.\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349483, "text": "TITLE:\n Chief Complaint: Fever and HOTN\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 46 y.o. F w/ syndrom, s/p multiple bowel resections w/ short\n gut syndrome on chronic TPN, multiple recurrent line infections and\n vascular occlusions. Transferred for fever and HOTN, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n LINES D/C'D - temporary line placed\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n - Surgical evaluation for abdominal pain - non-surgical\n - progression of discitis seen on lumbar spine imaging\n History obtained from Medical records, HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, better\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: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 65 (63 - 102) bpm\n BP: 104/57(74) {79/45(56) - 117/62(82)} mmHg\n RR: 13 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 2,187 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 2,187 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 759 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, ostomy in place, tender B/L LQ,\n no rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, pale\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): AAO x 3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 251 K/uL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: C.diff - negative x1, 2 pending\n BCx\n pending & \n Assessment and Plan\n 46 yo with hx Gardners syndrome. Admited to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n SEPSIS - Klebsiella bacteremia, possible sources include line\n infection, discitis. Overnight BP and lactate improved, WBC trending\n down\n - femoral line d/c'd yesterday, temporary midline place at IR\n - f/u repeat BCx, send surveillance BCx\n - continue linezolid for VRE UTI & meropenem for bacteremia\n - d/c PO vanco/flagyl, send repeat C.diff today\n - continue IVF today, wean levophed as able to keep MAP >55-60, PRN\n boluses for SBP<85\n - hold Celexa given linezolid\n #Abdominal pain - stable to mildly improved, LFTs stable and w/u thus\n far unrevealing. Surgical evaluation appreciated.\n - serial exams today\n - defer abdominal CT for now, but low threshold if worsening exam\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n - cont fentanyl patch\n ARF improved with IVF, likely pre-renal\n - f/u lytes/Cr today, continue IVF as above\n # FEN -\n - PO trial of clears today\n - holding TPN while lines out\n ICU Care\n Nutrition:\n Comments: PO diet, holding TPN for now\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Comments: R Midline\n Prophylaxis:\n DVT: SQ UF Heparin\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: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2145-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349387, "text": "TITLE:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o back pain/abdominal pain throughout shift .\n Action:\n Pt repositioned, given backrub, and pt given dilaudid 0.25mg IV q3h.\n Response:\n Pt resting comfortably after interventions.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n Hypotension (not Shock)\n Assessment:\n Pt with SBP 70\ns-90\ns throughout the shift.\n Action:\n Pt given numerous fluid boluses, A-line placed, and pt started on\n levophed drip.\n Response:\n Pt with SBP 90\ns and MAP\ns >65.\n Plan:\n Keep MAP\ns >65 and continue fluid/levophed drip.\n" }, { "category": "Nursing", "chartdate": "2145-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349388, "text": "TITLE:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o back pain/abdominal pain throughout shift .\n Action:\n Pt repositioned, given backrub, and pt given dilaudid 0.25mg IV q3h.\n Response:\n Pt resting comfortably after interventions.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n Hypotension (not Shock)\n Assessment:\n Pt with SBP 70\ns-90\ns throughout the shift.\n Action:\n Pt given numerous fluid boluses, A-line placed, and pt started on\n levophed drip.\n Response:\n Pt with SBP 90\ns and MAP\ns >65.\n Plan:\n Keep MAP\ns >65 and continue fluid/levophed drip.\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349442, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n 1.placed a-line\n 2. bolused 4L LR (5300cc+)\n 3.started levophed, weaned down overnight\n 4.IR removed right femoral CVL, placed right arm midline\n 5.empiric coverage of c. diff with flagyl and PO vanc\n 6. dc'd zosyn, added meropenem\n 7.lactate trending down\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 07:04 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 (96.9\n HR: 65 (63 - 102) bpm\n BP: 95/60(67) {70/36(44) - 95/60(67)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 1,843 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 1,843 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 415 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///21/\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 251 K/uL\n 9.3 g/dL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPOTENSION (NOT SHOCK)\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections now with\n limited access and Klebsiella, CoNS bactermia and Klebsiella UTI and\n hypotension on Linezolid and ZOsyn\n .\n Plan:\n =====\n Hypotension: could be due to increased ostomy output vs septic shock.\n Not going for septic shock is lack of hypo/hyperthermia, lack of\n leuckocytosis, lack of tachypnea or tachycardia. Also, per report OSH\n CT Abdomen negative, abdominal US negative for abscess here. Also\n surveillance BCx have been negative here. Of note, patient does have a\n history of line associated fungemia.\n - Will bolus with LR via tunnelled Hickman\n - Will use peripheral Levo as needed, per report from patient,\n baseline BP is 80\n - Will continue Linezolid/Zosyn\n - Cortisol in am\n - Will discuss empiric Fungal coverage on rounds.\n - Line when stable via IR\n - Image when stable\n - culture ostomy output\n .\n Klebsiella bacteremia/UTI:\n - Continue Linezolid/Zosyn\n - Appreciate ID recs\n ICU Care\n Nutrition: TPN\n Glycemic Control: Insulin in TPN\n Lines:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349450, "text": "TITLE:\n Chief Complaint: Fever and HOTN\n HPI:\n 46 y.o. F w/ syndrom, s/p multiple bowel resections w/ short\n gut syndrome on chronic TPN, multiple recurrent line infections and\n vascular occlusions. Transferred for fever and HOTN, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n LINES D/C'D - temporary line placed\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n - Surgical evaluation for abdominal pain - non-surgical\n - discitis seen on lumbar spine imaging\n History obtained from Medical records, HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, better\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: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 65 (63 - 102) bpm\n BP: 104/57(74) {79/45(56) - 117/62(82)} mmHg\n RR: 13 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 2,187 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 2,187 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 759 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, ostomy in place, tender B/L LQ,\n no rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, pale\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): AAO x 3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 251 K/uL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: C.diff - negative x1\n BCx - pending\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION - Klebsiella bacteremia, possible\n sources include line infection, discitis\n - femoral line d/c'd yesterday\n - f/u repeat BCx, send surveillance BCx\n - continue linezolid for VRE UTI/meropenem for bacteremia\n - d/c PO vanco/flagyl, send repeat C.diff\n - continue IVF today, MAP >55-60\n - hold Celexa given linezolid\n #Abdominal pain - stable to mildly improved\n - serial exams\n - defer abdominal CT for now\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n - cont fentanyl patch\n ARF - resolved with IVF, likely pre-renal\n - f/u lytes/Cr\n # FEN -\n - PO trial of clears today\n - holding TPN while lines out\n ICU Care\n Nutrition:\n Comments: PO diet, holding TPN for now\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Comments: R Midline\n Prophylaxis:\n DVT: SQ UF Heparin\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: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349459, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n 1.placed a-line\n 2. bolused 4L LR (5300cc+)\n 3.started levophed, weaned down overnight\n 4.IR removed right femoral CVL, placed right arm midline\n 5.empiric coverage of c. diff with flagyl and PO vanc\n 6. dc'd zosyn, added meropenem\n 7.lactate trending down\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 07:04 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 (96.9\n HR: 65 (63 - 102) bpm\n BP: 95/60(67) {70/36(44) - 95/60(67)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 1,843 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 1,843 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 415 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Gen: awake, alert\n Cardio: RRR, no m/g/r\n Pulm: CTA b/l\n GI abd tenderdiffusely, not distended\n Ext: no edema\n Labs / Radiology\n 251 K/uL\n 9.3 g/dL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections s/p femoral\n line removal, on meropenem, linezolid, IV flagyl, PO vancomycin\n #Hypotension: Likely from septic shock. History of klebsiella\n Bacteremia with indwelling femoral line. Treated through line once,\n presenting later with worsening hypotension. Femoral line was removed\n on , with plan of re-siting line in a couple of days once blood\n cultures remain negative. Baseline SBP in 80-90\ns, persistenly in 70\n yesterday despite being 5Lpositive. Levophed added with goal MAP\n > 60.\n -meropenem for klebsiella Bacteremia\n -linezolid for VRE UTI\n -LR boluses\n -re-site permanent line in days. If unable to replace, will require\n trans-hepatic venous access.\n .#Leukocytosis: wbc 57 with over 90% neutrophils, decreased to 29.3\n overnight. Surgery consulted given patient has tender abdomen, concern\n for C.Diff. treated empirically with flagyl and Po vanc. C.Diff\n negative X1, abdominal exam not too concerning, re-examined lumbar CT\n for abdominal pathology and CT did not reveal source of leukocytosis.\n Probably secondary to discitis/osteomyelitis, UTI, Bacteremia.\n -DC flagyl and PO Vanc\n -continue meropenem and linezolid\n -re check stool for C.Diff\n -discontinue celexa in setting of linezolid administration\n -abdominal CT if clinical picture worsens\n #ARF: baseline Cr 0.6, ncreased to 1.4 yesterday, decreased to 1.0\n today after 5L of LR. U lytes prerenal.\n -continue with hydration, bolus as necessary\n ICU Care\n Nutrition: holding TPN, no access. PO diet\n Glycemic Control: Insulin in TPN\n Lines:\n Tunneled (Hickman) Line\n midline 06:47 AM\n 20 Gauge - 06:49 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2145-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349470, "text": "TITLE:\n Chief Complaint: Fever and HOTN\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 46 y.o. F w/ syndrom, s/p multiple bowel resections w/ short\n gut syndrome on chronic TPN, multiple recurrent line infections and\n vascular occlusions. Transferred for fever and HOTN, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n BLOOD CULTURED - At 09:32 PM\n BLOOD CULTURED - At 04:31 AM\n STOOL CULTURE - At 06:30 AM\n LINES D/C'D - temporary line placed\n MIDLINE - START 04:00 PM\n TUNNELED (HICKMAN) LINE - STOP 04:05 PM\n L thigh\n ARTERIAL LINE - START 05:30 PM\n - Surgical evaluation for abdominal pain - non-surgical\n - discitis seen on lumbar spine imaging\n History obtained from Medical records, HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Linezolid - 10:20 PM\n Metronidazole - 12:00 AM\n Meropenem - 06:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Hydromorphone (Dilaudid) - 04:45 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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Gastrointestinal: Abdominal pain, better\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: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 65 (63 - 102) bpm\n BP: 104/57(74) {79/45(56) - 117/62(82)} mmHg\n RR: 13 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,171 mL\n 2,187 mL\n PO:\n TF:\n IVF:\n 8,171 mL\n 2,187 mL\n Blood products:\n Total out:\n 2,640 mL\n 1,428 mL\n Urine:\n 1,405 mL\n 990 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,531 mL\n 759 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, chronically ill appearing\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, ostomy in place, tender B/L LQ,\n no rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, pale\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): AAO x 3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 251 K/uL\n 91 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.5 %\n 29.3 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n Plt\n 332\n 287\n 269\n 234\n 251\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: C.diff - negative x1\n BCx - pending\n Assessment and Plan\n 46 yo with hx Gardners syndrome. Admited to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n SEPSIS - Klebsiella bacteremia, possible sources include line\n infection, discitis. Overnight BP and lactate improved\n - femoral line d/c'd yesterday, temporary midline place at IR\n - f/u repeat BCx, send surveillance BCx\n - continue linezolid for VRE UTI & meropenem for bacteremia\n - d/c PO vanco/flagyl, send repeat C.diff today\n - continue IVF today, MAP >55-60, PRN boluses for SBP<85\n - hold Celexa given linezolid\n #Abdominal pain - stable to mildly improved, LFTs stable and w/u thus\n far unrevealing. Surgical evaluation appreciated.\n - serial exams today\n - defer abdominal CT for now, but low threshold if worsening exam\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n - cont fentanyl patch\n ARF improved with IVF, likely pre-renal\n - f/u lytes/Cr today, continue IVF as above\n # FEN -\n - PO trial of clears today\n - holding TPN while lines out\n ICU Care\n Nutrition:\n Comments: PO diet, holding TPN for now\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Comments: R Midline\n Prophylaxis:\n DVT: SQ UF Heparin\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: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349556, "text": "Edema, peripheral\n Assessment:\n Pt 9.5L + for LOS. 3l pos just yesterday. Pt has been receiving LR\n @200/hr cont. marginal bp. Peripheral edema +. Some pedal edema as\n well.\n Action:\n Elevate extremeties\n Response:\n Cont be be positive as bp remains marginal\n Plan:\n Cont plan as above.\n" }, { "category": "Nursing", "chartdate": "2145-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349426, "text": "Ms is a 46-year old woman with a history of syndrome\n s/p colectomy in , multiple small bowel resections with subsequent\n short gut syndrome, and TPN dependent since . She has a history of\n multiple line infections and recurrent UTIs. Pt initially presented to\n an OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI, and was transferred to for further\n management. She has been treated with Linezolid for VRE in urine and\n staph Bacteremia, and Zosyn for klebsiella Bacteremia since admission.\n On the morning of , MICU was called to evaluate the pt for\n hypotension 60/pal in the setting of increased ostomy outout and\n decreased urine output. Pt transferred to MICU for further management\n of hypotension and possible sepsis. Since MICU admission, pt has been\n bolused several times with LR but persistent hypotension was\n started on levophed. Blood cultures have been sent from her midline,\n right radial aline, and tunneled catheter prior to removal.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain rated in abdomen. Described as aching, constant pain.\n Action:\n Dilaudid 0.25mg given Q3-4hrs PRN as needed with pt requesting approx\n Q3hrs.\n Response:\n Pain down to post pain medication and pt able to sleep/rest\n comfortably.\n Plan:\n Cont with frequent pain assessment. Treat pain PRN.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed 0.06mcg/kg/min with 1L LR bolus hanging.\n Action:\n Levophed titrated up initially to 0.08mcg/kg/min to maintain ABPm >65.\n Response:\n MAPs in 80s on 0.08mcg/kg/min of levophed, so levo titrated to 0.05\n with MAPs remaining in 70s.\n Plan:\n Cont to wean levophed as tolerated while keeping MAPs >65.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile but with WBC 33.9\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349437, "text": "Ms is a 46-year old woman with a history of syndrome\n s/p colectomy in , multiple small bowel resections with subsequent\n short gut syndrome, and TPN dependent since . She has a history of\n multiple line infections and recurrent UTIs. Pt initially presented to\n an OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI, and was transferred to for further\n management. She has been treated with Linezolid for VRE in urine and\n staph Bacteremia, and Zosyn for klebsiella Bacteremia since admission.\n On the morning of , MICU was called to evaluate the pt for\n hypotension 60/pal in the setting of increased ostomy outout and\n decreased urine output. Pt transferred to MICU for further management\n of hypotension and possible sepsis. Since MICU admission, pt has been\n bolused several times with LR but persistent hypotension was\n started on levophed. Blood cultures have been sent from her midline,\n right radial aline, and tunneled catheter prior to removal.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain rated in abdomen. Described as aching, constant pain.\n Action:\n Dilaudid 0.25mg given Q3-4hrs PRN as needed with pt requesting approx\n Q3hrs.\n Response:\n Pain down to post pain medication and pt able to sleep/rest\n comfortably.\n Plan:\n Cont with frequent pain assessment. Treat pain PRN.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed 0.06mcg/kg/min with 1L LR bolus hanging.\n Action:\n Levophed titrated up initially to 0.08mcg/kg/min to maintain ABPm >65.\n Cont on LR @ 200cc/hr.\n Response:\n MAPs in 80s on 0.08mcg/kg/min of levophed, so levo titrated to 0.03\n with MAPs remaining in 70s and cuff pressures correlating.\n Plan:\n Cont to wean levophed as tolerated while keeping MAPs >65. Cont with\n fluid repletion in setting of high ostomy output, low UOP, and probable\n dehydration.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile but with WBC 33.2.\n Action:\n On multiple IV abx. Blood cultures drawn via aline. Blood Cx pending\n from midline and previously removed tunneled catheter. Stool sample\n sent for cdiff as pt is currently being empirically treated in the\n setting of her high WBC.\n Response:\n WBC 29.3 this am. Remains afebrile.\n Plan:\n Cont IV abx, follow culture data.\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349663, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Consistently decreased sats down to 88 despite increase in O2. LS with\n faint crackles. Denies SOB. CXR showing small collapse on left.\n Action:\n IVF stopped. Incentive spirometry in use.\n Response:\n Slight improvement in sats. Now > 90%\n Plan:\n Encourage use of incentive spirometry; encourage mobilization as\n tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain; abdominal pain (situational this admission).\n Action:\n Fentanyl patch; lidocaine patch for back pain; dilaudid IVP for acute\n abdominal pain.\n Response:\n Desired effect from Dilaudid. Does not stop pain but definite decrease\n to tolerable level.\n Plan:\n Continue with prescribed regimen.\n Sepsis without organ dysfunction\n Assessment:\n Positive bld cx from for gram negative rods. Also being treated\n for VRE in urine.\n Action:\n Linezolid for VRE; Meropenem for gram neg rods.\n Response:\n Pnd.\n Plan:\n Linezolid for total of 7 days, completed tomorrow. Continue with\n surveillance cultures.\n Additional info: Sent surveillance cx from art line but unable to draw\n from midline. Arterial line positional with dampened waveform.\n OVERALL PLAN:\n Will remain in MICU secondary to increased O2 requirements.\n" }, { "category": "Nursing", "chartdate": "2145-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349424, "text": "Ms is a 46-year old woman with a history of syndrome\n s/p colectomy in , multiple small bowel resections with subsequent\n short gut syndrome, and TPN dependent since . She has a history of\n multiple line infections and recurrent UTIs. Pt initially presented to\n an OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI, and was transferred to for further\n management. She has been treated with Linezolid for VRE in urine and\n staph Bacteremia, and Zosyn for klebsiella Bacteremia since admission.\n On the morning of , MICU was called to evaluate the pt for\n hypotension 60/pal in the setting of increased ostomy outout and\n decreased urine output. Pt transferred to MICU for further management\n of hypotension and possible sepsis. Since MICU admission, pt has been\n bolused several times with LR but persistent hypotension was\n started on levophed. Blood cultures have been sent from her midline,\n right radial aline, and tunneled catheter prior to removal.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain rated in abdomen. Described as aching, constant pain.\n Action:\n Dilaudid 0.25mg given Q3-4hrs PRN as needed with pt requesting approx\n Q3hrs.\n Response:\n Pain down to post pain medication and pt able to sleep/rest\n comfortably.\n Plan:\n Cont with frequent pain assessment. Treat pain PRN.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed 0.06mcg/kg/min with 1L LR bolus hanging.\n Action:\n Levophed titrated up initially to 0.08mcg/kg/min to maintain ABPm >65.\n Response:\n MAPs in 80s on 0.08mcg/kg/min of levophed, so levo titrated to 0.05\n with MAPs remaining in 70s.\n Plan:\n Cont to wean levophed as tolerated while keeping MAPs >65.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349548, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor\n but then dropped her bp. nd she was transferred here for hypotension in\n the setting of limited access.\n Since admission she has been continued on Zosyn for the Klebsiella and\n Linezolid was added for the VRE in urine and Coag negative Staph\n bacteremia. She reports intermitted sharp nonradiating lower\n abdominal/back pain pain for the past several days. She reports\n decreased PO intake with associated nausea. She denies vomiting. She\n denies fevers or chills over the past several days, but hasn\nt been\n feeling well.\n Hypotension (not Shock)\n Assessment:\n BPs in 110s beginning of shift.\n Action:\n Turned Levophed gtt off. BP stable for ~1.5hrs but decreased to\n 70s-80s. Gave fluid bolus 1Liter LR.\n Response:\n Responsive to fluid bolus with increase to 80s-90s. Patient\ns baseline\n BP 80s.\n Plan:\n Fluid boluses as required.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain which started in . Also has abdominal pain\n especially on palpation.\n Action:\n Lidocaine patch on lower back. Receiving Dilaudid 0.25mcg.\n Response:\n Desired effect with Dilaudid.\n Plan:\n Lidocaine patch off at ; Diluadid IVP Q3 hrs prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349549, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain. Also has abdominal pain.\n Action:\n Lidocaine patch on lower back. Receiving Dilaudid 0.25mcg q 3hrs.\n Response:\n Good effect with Dilaudid.\n Plan:\n Lidocaine patch off at ; Diluadid IVP Q3 hrs prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n BP\ns w/ maps >60. 80-90 sys via r radial aline. 10-15 pts\n lower. Mentating.\n Action:\n Levophed remains off. Ivf of lr remain at 200/hr\n Response:\n Maps remain >60\n Plan:\n Continue to maint maps of 60\n" }, { "category": "Nursing", "chartdate": "2145-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349659, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Consistently decreased sats down to 88 despite increase in O2. LS with\n faint crackles. Denies SOB. CXR showing small collapse on left.\n Action:\n IVF stopped. Incentive spirometry in use.\n Response:\n Slight improvement in sats. Now > 90%\n Plan:\n Encourage use of incentive spirometry; encourage mobilization as\n tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain; abdominal pain (situational this admission).\n Action:\n Fentanyl patch; lidocaine patch for back pain; dilaudid IVP for acute\n abdominal pain.\n Response:\n Desired effect from Dilaudid. Does not stop pain but definite decrease\n to tolerable level.\n Plan:\n Continue with prescribed regimen.\n Sepsis without organ dysfunction\n Assessment:\n Positive bld cx from for gram negative rods. Also being treated\n for VRE in urine.\n Action:\n Linezolid for VRE; Meropenem for gram neg rods.\n Response:\n Pnd.\n Plan:\n Linezolid for total of 7 days, completed tomorrow. Continue with\n surveillance cultures.\n Additional info: Sent surveillance cx from art line but unable to draw\n from midline.\n" }, { "category": "Physician ", "chartdate": "2145-09-24 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 349348, "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 46 yo with hx Gardners syndrome. Admiteed to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n Patient admitted from: \n History obtained from Patient, H\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\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 Colectomy 85, multiple SBO with muliple Bowel resections\n Short gut syndrome\n TPN (via indwelling line with multiple infections): Klebsiella\n bactermia (Cefaz). TPN since \n - fungemia\n - staph epi sepsis\n extensive venous occlusions with stents: right IJ, right\n brachiocephalic, IVC stents,\n Hx of GIB\n B/l hip fractures s/p ORIF\n s/p TAH and BSO\n 6 sibs with gardners syndrome (as did dad)\n Occupation:\n Drugs: none\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Gastrointestinal: Abdominal pain, Nausea\n Flowsheet Data as of 09:15 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 88 (88 - 88) bpm\n BP: 70/40(53) {70/40(53) - 70/40(53)} mmHg\n RR: 18 (18 - 18) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n PO:\n TF:\n IVF:\n 525 mL\n Blood products:\n Total out:\n 0 mL\n 45 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 484 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\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: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, ostomy mid\n abdomen. Green out put.\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 332 K/uL\n 29.2 %\n 9.2 g/dL\n 86 mg/dL\n 1.4 mg/dL (0.6)\n 9 mg/dL\n 20 mEq/L\n 107 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 57.0 K/uL\n [image002.jpg]\n 06:45 AM\n WBC\n 57.0\n Hct\n 29.2 (34)\n Plt\n 332 (470)\n Cr\n 1.4\n Glucose\n 86\n Other labs: PT / PTT / INR:15.3/39.4/1.4, ALT / AST:33/29, Alk Phos / T\n Bili:421/0.4, LDH:158 IU/L, Ca++:7.0 mg/dL, Mg++:0.8 mg/dL, PO4:3.4\n mg/dL\n Imaging: Abd US : no abscess\n TTE : EF 60-70% no Veg.\n CXR :\n CT L spine (I-) : L4-5 discitis/osteo\n Microbiology: Blood clx : NGTD\n : NGTD\n c. dif (pending) : pending\n Assessment and Plan\n 46 yo with hx Gardners syndrome. Admited to OSH with lower abd\n pain and lower back pain grew out klebsiella and coag neg staph in\n blood and VRE in urine. Hypotensive overnight with increased ostomy\n output in past few days with SBP in the 60's mmHg.\n >Hypotension/Sepsis: concern for multiple sources including line (which\n was last changed here in and has been treated through at\n least one line infection), also with rapid rise in WBC and ostomy\n output is concerning for c. dif given recent antibiosis, current abx\n include:\n Linezolid\n Pip-Tazo\n Flagyl PO (she is not taking)\n - Will continue : Linezolid and Pip-Tazo\n and Add:\n - Vanco PO\n - Flagyl IV\n to cover c.dif. we will image CT abd with PO contrast (no I contrast).\n Surgery Consult today.\n -Call IR to remove and replace line\n -Follow up with ID re: empiric coverage for fungal pathogens (check 1,3\n glucan, galactomannan)\n - At some point will need to have ortho see her\n - Check lactate now and fluid resusc with goal MAP > 60 mmHg.Has\n received about 3L and will need to Fluid bolus with LR. Will use NE as\n first pressor.\n - defer steroids given concern for c. dif\n - check amylase and lipase ? pancreatitis\n >Electrolytes: replete as needed and check 4-6hrs today, Defer TPN\n >Renal failure: likely pre-renal. Check urine lytes. Will cont to vol\n resus with LR bolus\n Other issues\n ICU Care\n Nutrition:\n Comments: defer TPN\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: She is tenuous from a hemodynamic\n perpsective ( despite lack of HR response to current level of stress)\n but has the potential for cardiovascular collapse if bacteremia does\n not clear with line changes and ABx therapy. Her surgical risk ( if\n needed) is inordinately high at this time.\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 349528, "text": "Ms is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. SHe initially went to an\n OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI and was transferred here and put on Linezolid and\n Zosyn. MICU was called to eval for hypotension 60/pal on the floor.\n Patient has had increased ostomy outout, decreased urine output. She\n has been mentating faily well. Multiple attempts at EJ were done on\n the floor and she was transferred here for hypotension in the setting\n of limited access.\n Since admission she has been continued on Zosyn for the Klebsiella and\n Linezolid was added for the VRE in urine and Coag negative Staph\n bacteremia. She reports intermitted sharp nonradiating lower\n abdominal/back pain pain for the past several days. She reports\n decreased PO intake with associated nausea. She denies vomiting. She\n denies fevers or chills over the past several days, but hasn\nt been\n feeling well.\n Hypotension (not Shock)\n Assessment:\n BPs in 110s beginning of shift.\n Action:\n Turned Levophed gtt off. BP stable for ~1.5hrs but decreased to\n 70s-80s. Gave fluid bolus 1Liter LR.\n Response:\n Responsive to fluid bolus with increase to 80s-90s. Patient\ns baseline\n BP 80s.\n Plan:\n Fluid boluses as required.\n Pain control (acute pain, chronic pain)\n Assessment:\n Chronic back pain which started in . Also has abdominal pain\n especially on palpation.\n Action:\n Lidocaine patch on lower back. Receiving Dilaudid 0.25mcg.\n Response:\n Desired effect with Dilaudid.\n Plan:\n Lidocaine patch off at ; Diluadid IVP Q3 hrs prn.\n Sepsis without organ dysfunction\n Assessment:\n Gram neg rods both bottles from .\n Action:\n Receiving Meropenem on sched. Additional bld cx sent from Midline\n today.\n Response:\n PND.\n Plan:\n Follow culture data and send surveillance cultures as ordered;\n Meropenem as scheduled.\n" }, { "category": "Nursing", "chartdate": "2145-09-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 349820, "text": "Pt is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. She admitted to the floor,\n subsequently dropped her bp, and came to the micu also in light of\n limited access as well.\n 2 lumen picc in IR . BP now improved, SBP 90-110\ns MAP 70-85 mm of\n hg..\n Significant Events : *** Lasix 20 Mg IV X1 given with good response,\n Goal neg 1 lit.\n **** sitting up @ chair for \n hrs , tolerated well.\n ****PA/ Lat CXR .\n **** call out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 90 -94% on 4 l nasal cannula. Sat dropped to high 80\ns when @\n chair. Lungs diminished at base bilat & clear at upper lobes.\n Action:\n Using IS when she is awake./ sitting up. CXR PA/ Lat at 1500\n hrs. Lasix 20 mg IV X1 given.\n Response:\n Satting 90-93% mostly. UO good.\n Plan:\n Titrate o2 as needed. Encourage to use IS more often. Plan to check PM\n lytes, awaiting result.\n Pain control (acute pain, chronic pain)\n Assessment:\n Conts to have abd pain. IV dilaudid 0.25 mg q3 prn. Fentanyl patch @\n RUA (placed on ), Lidocaine patch at lower back ( at 0800\n hrs)\n Action:\n Medicated w/iv dilaudid for abd pain.\n Response:\n Pain tolerable w/ dilaudid.\n Plan:\n Cont to assess. Monitor for pain, resp comprimise\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349825, "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: GNR sepsis\n 24 Hour Events:\n BLOOD CULTURED - At 02:48 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n diffusely (but less then previous exam)\n Extremities: Right: 1+, Left: 1+\n Neurologic: Attentive, Responds to: verbal stimuli. Moving all ext.\n Labs / Radiology\n 9.2 g/dL\n 269 K/uL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI and resultant septic shock.\n SEPSIS - likely line sepsis, line removed with + blood clx\n (Kleb pneumo pip- ), WBC trending down and afebrile with\n subsequent neg clx ( and ). Concern remains for chronic but\n worsening discitis (concerning for source of repeated infection: osteo)\n - continues on meropenem (Day 3), will change back to Pip- for 14\n day course.\n - continues on linezolid for UTI, last day today. (7 day course)`\n - needs f/u w/ ortho for discitis once acute issues are resolved: may\n need bx of L4-5\n - ID following appreciate input.\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic, now\n SBP near 100 mmHg\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal 1L out with lasix prn\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - check PA and lateral CXR to eval RLL effusion and LLL collapse\n - chest PT, OOB to chair, incentive spirometry for LLL atelectasis\n - goal net neg 1L\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO (will need new TPN at some point)\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349589, "text": "TITLE:\n Chief Complaint: HOTN, abdominal pain\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 46 yo F w/ syndrome, multiple bowel resections and short gut\n 24 Hour Events:\n Flagyl and PO vanco stopped after C.diff negative\n Diet advanced\n BCx from - GNRs 2/4 bottles\n New O2 requirement today\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Meropenem - 06:05 AM\n Linezolid - 07:57 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:58 AM\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Other medications:\n Lidoderm, fent patch,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Pain: Mild\n Pain location: abdomen, unchanged\n Flowsheet Data as of 08:56 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: 36.4\nC (97.6\n HR: 73 (69 - 79) bpm\n BP: 92/52(67) {80/48(60) - 102/78(245)} mmHg\n RR: 15 (11 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 2,363 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 2,363 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 1,213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, chronically ill\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : ,\n Diminished: B/L bases)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 230 K/uL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - very suboptimal film, rotated\n New R effusion\n Microbiology: BCx () - GNR\n BCx () - pending\n C.diff (-) x3\n Assessment and Plan\n SEPSIS - likely line sepsis, line removed , WBC trending down,\n afebrile\n - continues on meropenem (Day 3)\n - continues on linezolid for UTI (today day 6 of 7)\n - f/u surveillance cultures\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal even today\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, no SOB\n - as above, d/c IVF\n - consider lasix in PM if BP remains adequate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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: 25 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349593, "text": "Chief Complaint:\n 24 Hour Events:\n - cdiff neg x 1, flagyl and PO vanc discontinued per ID recs\n - 2nd cdiff sample sent\n - d/c'd celexa given concern for SSRI syndrome on Linezolid\n - diet advanced\n - blood cx from growing GNR; surveillance cx sent\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:10 PM\n Meropenem - 06:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Hydromorphone (Dilaudid) - 01:15 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 07:30 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: 36.2\nC (97.1\n HR: 74 (63 - 79) bpm\n BP: 94/55(70) {80/48(60) - 112/78(245)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 1,890 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 1,890 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 740 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, pale\n Eyes / Conjunctiva: PERRL\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: Crackles :\n )\n Abdominal: Soft, Bowel sounds present, Tender:\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 230 K/uL\n 9.0 g/dL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - pending\n Microbiology: blood cx: GNR 2/2 bottles from left groin catheter\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections s/p femoral\n line removal, on meropenem, linezolid, IV flagyl, PO vancomycin\n #Hypotension: Likely from septic shock. History of klebsiella\n Bacteremia with indwelling femoral line. Treated through line once,\n presenting later with worsening hypotension. Femoral line was removed\n on , with plan to resite line in a couple of days once blood\n cultures remain negative. Baseline SBP in 80-90\n -meropenem for klebsiella bacteremia, day #3, follow-up organism\n identification and sensitivities\n -linezolid for VRE UTI, day #6 of 7\n -LR boluses as needed to maintain MAP>60\n -re-site permanent line in days. If unable to replace, will require\n trans-hepatic venous access.\n -surveillance blood cx\n #Leukocytosis: wbc 57 with over 90% neutrophils, decreased to 29.3\n overnight. Surgery consulted given patient has tender abdomen, concern\n for C.Diff. Initially treated empirically with flagyl and Po vanc,\n then d/c\nd after C.Diff negative X1. Surgery consulted and reported\n abdominal exam too concerning. Re-examined lumbar CT for abdominal\n pathology and CT did not reveal source of leukocytosis. Possibly\n secondary to discitis/osteomyelitis, UTI, bacteremia. Now improving on\n antibiotic therapy.\n -continue meropenem and linezolid\n - f/u cdiff toxin #2\n # Depression:\n -discontinue celexa in setting of linezolid administration\n #ARF: baseline Cr 0.6, now at 1.0 in the setting of recent\n hypotension. Good UOP. Suspect prerenal etiology vs. element of ATN.\n -continue with hydration, bolus as necessary\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer: PPI not indicated.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2145-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349581, "text": "Chief Complaint:\n 24 Hour Events:\n - cdiff neg x 1, flagyl and PO vanc discontinued per ID recs\n - 2nd cdiff sample sent\n - d/c'd celexa given concern for SSRI syndrome on Linezolid\n - diet advanced\n - blood cx from growing GNR; surveillance cx sent\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:10 PM\n Meropenem - 06:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Hydromorphone (Dilaudid) - 01:15 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 07:30 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: 36.2\nC (97.1\n HR: 74 (63 - 79) bpm\n BP: 94/55(70) {80/48(60) - 112/78(245)} mmHg\n RR: 12 (11 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,643 mL\n 1,890 mL\n PO:\n 240 mL\n TF:\n IVF:\n 7,403 mL\n 1,890 mL\n Blood products:\n Total out:\n 3,628 mL\n 1,150 mL\n Urine:\n 2,050 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,015 mL\n 740 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///21/\n Physical Examination\n General Appearance: Thin, pale\n Eyes / Conjunctiva: PERRL\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: Crackles :\n )\n Abdominal: Soft, Bowel sounds present, Tender:\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 230 K/uL\n 9.0 g/dL\n 72 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 112 mEq/L\n 140 mEq/L\n 27.1 %\n 12.9 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n Plt\n 332\n 287\n 269\n \n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n Glucose\n 86\n 70\n 167\n 91\n 72\n Other labs: PT / PTT / INR:14.9/36.9/1.3, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.6 mg/dL, Mg++:1.4 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR - pending\n Microbiology: blood cx: GNR 2/2 bottles from left groin catheter\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections s/p femoral\n line removal, on meropenem, linezolid, IV flagyl, PO vancomycin\n #Hypotension: Likely from septic shock. History of klebsiella\n Bacteremia with indwelling femoral line. Treated through line once,\n presenting later with worsening hypotension. Femoral line was removed\n on , with plan of re-siting line in a couple of days once blood\n cultures remain negative. Baseline SBP in 80-90\ns, persistenly in 70\n yesterday despite being 5Lpositive. Levophed added with goal MAP\n > 60.\n -meropenem for klebsiella Bacteremia\n -linezolid for VRE UTI\n -LR boluses\n -re-site permanent line in days. If unable to replace, will require\n trans-hepatic venous access.\n #Leukocytosis: wbc 57 with over 90% neutrophils, decreased to 29.3\n overnight. Surgery consulted given patient has tender abdomen, concern\n for C.Diff. treated empirically with flagyl and Po vanc. C.Diff\n negative X1, abdominal exam not too concerning, re-examined lumbar CT\n for abdominal pathology and CT did not reveal source of leukocytosis.\n Probably secondary to discitis/osteomyelitis, UTI, Bacteremia.\n -DC flagyl and PO Vanc\n -continue meropenem and linezolid\n - f/u cdiff toxin #2\n -discontinue celexa in setting of linezolid administration\n -abdominal CT if clinical picture worsens\n #ARF: baseline Cr 0.6, ncreased to 1.4 yesterday, decreased to 1.0\n today after 5L of LR. U lytes prerenal.\n -continue with hydration, bolus as necessary\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:49 AM\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 349751, "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 BLOOD CULTURED - At 02:48 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\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), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender:\n diffusely\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 269 K/uL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 46 yo F w/ syndrome, multiple bowel resections with resultant\n short gut syndrome on chronic TPN since , s/p multiple vascular\n occlusions with 27 stents, admitted with ESBL Klebsiella bacteremia and\n VRE UTI, septic shock.\n SEPSIS - likely line sepsis, line removed , WBC trending down,\n Afebrile, chronic but worsening discitis\n - continues on meropenem (Day 3)\n - continues on linezolid for UTI (today day 6 of 7)\n - f/u surveillance cultures, f/u speciation/sensitivities of BCx\n GNRs\n - needs f/u w/ ortho for discitis once acute issues are resolved\n - ID following\n HYPOTENSION (NOT SHOCK) - baseline BP reported in 80's systolic\n - will stop IVF given total body overload, f/u UOP\n - tolerate MAP 55 as long as UOP and mental status maintained\n EDEMA, PERIPHERAL\n - will hold off on IVF (as above)\n - TBB goal even today\n HYPOXEMIA - in setting of aggressive IVF resuscitation, now on 4L w/\n new B/L pleural effusions, and LLL collapse, no SOB\n - as above, d/c IVF, consider lasix in PM if BP remains adequate\n - chest PT, OOB to chair, incentive spirometry for LLL collapse\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO (will need new TPN at some point)\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2145-09-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 349754, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 02:48 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:00 AM\n Metronidazole - 08:00 AM\n Linezolid - 08:40 PM\n Meropenem - 05:41 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 12:04 AM\n Hydromorphone (Dilaudid) - 05:00 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: 69 (69 - 79) bpm\n BP: 101/71(81) {83/52(66) - 102/99(101)} mmHg\n RR: 10 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,450 mL\n 353 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 3,210 mL\n 233 mL\n Blood products:\n Total out:\n 3,360 mL\n 750 mL\n Urine:\n 1,870 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 90 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\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 269 K/uL\n 9.2 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 7 mg/dL\n 111 mEq/L\n 137 mEq/L\n 28.5 %\n 8.2 K/uL\n [image002.jpg]\n 06:45 AM\n 08:47 AM\n 01:20 PM\n 09:33 PM\n 03:39 AM\n 04:47 AM\n 02:23 PM\n 04:12 AM\n WBC\n 57.0\n 31.4\n 44.8\n 33.2\n 29.3\n 12.9\n 8.2\n Hct\n 29.2\n 29.0\n 27.4\n 27.1\n 29.5\n 27.1\n 28.5\n Plt\n 332\n 287\n 269\n \n 269\n Cr\n 1.4\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 86\n 70\n 167\n 91\n 72\n 90\n 87\n Other labs: PT / PTT / INR:13.6/35.9/1.2, ALT / AST:22/19, Alk Phos / T\n Bili:301/0.3, Amylase / Lipase:74/22, Differential-Neuts:93.0 %,\n Lymph:4.2 %, Mono:1.9 %, Eos:0.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.5\n g/dL, LDH:155 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections s/p femoral\n line removal, on meropenem, linezolid, IV flagyl, PO vancomycin\n #Hypotension: Likely from septic shock. History of klebsiella\n Bacteremia with indwelling femoral line. Treated through line once,\n presenting later with worsening hypotension. Femoral line was removed\n on , with plan to resite line in a couple of days once blood\n cultures remain negative. Baseline SBP in 80-90\n -meropenem for klebsiella bacteremia, day #3, follow-up organism\n identification and sensitivities\n -linezolid for VRE UTI, day #6 of 7\n -LR boluses as needed to maintain MAP>60\n -re-site permanent line in days. If unable to replace, will require\n trans-hepatic venous access.\n -surveillance blood cx\n #Leukocytosis: wbc 57 with over 90% neutrophils, decreased to 29.3\n overnight. Surgery consulted given patient has tender abdomen, concern\n for C.Diff. Initially treated empirically with flagyl and Po vanc,\n then d/c\nd after C.Diff negative X1. Surgery consulted and reported\n abdominal exam too concerning. Re-examined lumbar CT for abdominal\n pathology and CT did not reveal source of leukocytosis. Possibly\n secondary to discitis/osteomyelitis, UTI, bacteremia. Now improving on\n antibiotic therapy.\n -continue meropenem and linezolid\n - f/u cdiff toxin #2\n # Depression:\n -discontinue celexa in setting of linezolid administration\n #ARF: baseline Cr 0.6, now at 1.0 in the setting of recent\n hypotension. Good UOP. Suspect prerenal etiology vs. element of\n ATN.\n -continue with hydration, bolus as necessary\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 04:00 PM\n Arterial Line - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Echo", "chartdate": "2145-09-23 00:00:00.000", "description": "Report", "row_id": 102835, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 63\nWeight (lb): 88\nBSA (m2): 1.37 m2\nBP (mm Hg): 90/50\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:53\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%). 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.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve. Normal mitral valve supporting structures. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNo TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler 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.\nNo masses or vegetations are seen on the aortic valve. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. No vegetation/mass is\nseen on the pulmonic valve. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the tricuspid regurgitation is reduced.\n\nIMPRESSION: no obvious vegetations\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Physician ", "chartdate": "2145-09-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 349315, "text": "Chief Complaint: hypotension/sepsis\n HPI:\n Ms is a 46-year old woman with a history of syndrome\n diagnosed at age 23 and s/p colectomy () and later small bowel\n resections with subsequent short gut syndrome on TPN since . She\n has had multiple line infections with mutliple organisms in past,\n multiple past UTIs who was admitted to with Klebsiella bacteremia\n and Klebsiella UTI refractory to treatment. SHe initially went to an\n OSH on with a sepsis picture with Klebsiella bacteremia and\n Klebsiella UTI and was transferred here and put on Linezolid and\n Zosyn. MICU was called to eval for hypotension 60/pal on the floor.\n Patient has had increased ostomy outout, decreased urine output. She\n has been mentating faily well. Multiple attempts at EJ were done on\n the floor and she was transferred here for hypotension in the setting\n of limited access.\n Since admission she has been continued on Zosyn for the Klebsiella and\n Linezolid was added for the VRE in urine and Coag negative Staph\n bacteremia. She reports intermitted sharp nonradiating lower\n abdominal/back pain pain for the past several days. She reports\n decreased PO intake with associated nausea. She denies vomiting. She\n denies fevers or chills over the past several days, but hasn\nt been\n feeling well.\n Of note, she has been seen by IR who knows her well and they are\n concerned they have run out of access sites. Sh ehas had extensive\n venous occlusions with repeat stenting including right internal jugular\n vein, right brachiocephalic vein, IVC, right femoral and common\n iliacs. She does report decreased\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n seizures;\n Compazine (Oral) (Prochlorperazine Maleate)\n Rash;\n Reglan (Oral) (Metoclopramide Hcl)\n Rash;\n Betadine Surgi-Prep (Topical) (Povidone-Iodine)\n blisters;\n Nausea/Vomiting\n Iodine; Iodine Containing\n Hives; Nausea/V\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDICATIONS\n Past medical history:\n Family history:\n Social History:\n 1. syndrome\n - diagnosed at age 23\n - s/p colectomy ()\n - repeated small bowel resections persistent polyp growth\n - short gut syndrome and on chronic TPN since \n 2. s/p dermoid cyst removal, originally in small bowel, then extended\n to ovaries\n 3. Fibromyalgia\n 4. Osteoporosis\n 5. History of fungemia- parapsilosis , non-albicans\n , \n 6. History of staph epi sepsis\n 7. Mutliple venous occlusions: recanalized and stented the right\n internal jugular vein, right brachiocephalic vein, which however has\n occluded because of poor inflow reconstructed now the inferior vena\n cava with kissing stent\n extensions into the high inferior vena cava. A long-term right femoral\n access which had been available also had scar-down and during her last\n admission in actually required stenting even of the right\n femoral and external iliac vein.\n 8. History of GI bleed\n 9. Scoliosis s/p repair\n 10. s/p bilateral hip fracture and ORIF\n 11. s/p TAH BSO\n 12. s/p \n Father with syndrome as do 6 of 8 siblings. Father also with\n pancreatitis; died at 42 from polyp blocking pancreatic duct. Diagnosed\n when sister was going to the marines, then had testing given her\n father's dx's and diagnosed w/ Gardners. Mother and relatives with HTN\n and resulting CVA. Sister with breast ca\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: Parenteral nutrition\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:33 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 88 (88 - 88) bpm\n BP: 70/40(53) {70/40(53) - 70/40(53)} mmHg\n RR: 18 (18 - 18) insp/min\n Total In:\n 175 mL\n PO:\n TF:\n IVF:\n 175 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 175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Physical Examination\n General Appearance: Thin, jovial\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\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: Tender: , midline abdominal\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 470\n 11.1\n 82\n 0.6\n 5\n 23\n 103\n 3.4\n 139\n 34.9\n 7.3\n [image002.jpg]\n Fluid analysis / Other labs: Sed Rate: 44\n CRP: 13.8\n Imaging: TTE (Complete) Done at 2:53:44 PM FINAL\n The left atrium is normal in size. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n 60-70%). There is no ventricular septal defect. The right ventricular\n cavity is dilated with normal free wall contractility. The aortic valve\n leaflets (3) appear structurally normal with good leaflet excursion and\n no aortic regurgitation. No masses or vegetations are seen on the\n aortic valve. The mitral valve appears structurally normal with trivial\n mitral regurgitation. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. The estimated pulmonary artery\n systolic pressure is normal. No vegetation/mass is seen on the pulmonic\n valve. There is no pericardial effusion.\n ABDOMEN U.S. (COMPLETE STUDY) Study Date of 8:46 AM\n IMPRESSION:\n 1. No fluid collections identified. No findings to suggest an abscess.\n 2. Mild splenomegaly.\n 3. Common hepatic duct at the upper limits of normal measuring 1.0 cm.\n No intrahepatic biliary dilatation seen. Correlation with LFTs is\n recommended.\n OSH CT abdomen without contrast: Per ER reports no abscess found, no\n hydronephrosis.\n Microbiology: Blood cx : NGTD\n OSH:\n ===\n Ucx ->100,000Klebsiella (R to amp, cipro, levo, bactrim, S to\n cefazolin, gentamicin, zosyn) and >100,000 VRE (amp and vanco\n resistant)\n Blood cx - Klebsiella pneumoniae to cefazolin, gent,\n zosyn and levo) CoNS\n Assessment and Plan\n 46 y.o female with syndrome s/p small and large bowel\n resection on chronic TPN and hx of multiple line infections now with\n limited access and Klebsiella, CoNS bactermia and Klebsiella UTI and\n hypotension on Linezolid and ZOsyn\n .\n Plan:\n =====\n Hypotension: could be due to increased ostomy output vs septic shock.\n Not going for septic shock is lack of hypo/hyperthermia, lack of\n leuckocytosis, lack of tachypnea or tachycardia. Also, per report OSH\n CT Abdomen negative, abdominal US negative for abscess here. Also\n surveillance BCx have been negative here. Of note, patient does have a\n history of line associated fungemia.\n - Will bolus with LR via tunnelled Hickman\n - Will use peripheral Levo as needed, per report from patient,\n baseline BP is 80\n - Will continue Linezolid/Zosyn\n - Cortisol in am\n - Will discuss empiric Fungal coverage on rounds.\n - Line when stable via IR\n - Image when stable\n - culture ostomy output\n .\n Klebsiella bacteremia/UTI:\n - Continue Linezolid/Zosyn\n - Appreciate ID recs\n ICU Care\n Nutrition: TPN\n Glycemic Control: Insulin in TPN\n Lines:\n Tunneled (Hickman) Line - 06:47 AM\n 20 Gauge - 06:49 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n This note was drafted prior to her WBC count returning. Given this new\n leuckocytosis of 57K, she is likely septic at this point. Her CT back\n looks like discitis/osteomyelitis @ L4-5. Will recheck CBC to validate\n this CBC.\n Of note, Positive culture from OSH on positive for Klebsiella.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:59 ------\n Updated plan:\n Concern for possible c diff vs, abdominal perforation vs sepsis.\n - Repeat CBC\n - Call IR for access and L fem line needs to be removed\n - Call surgery for concern of surgical abdomen\n - KUB\n - Stat lactate and q4 hr lactates\n - Hydrate with LR, bolus as needed for BP, MAP > 60, pressors\n - Touch base with ID regarding empiric fungal coverage\n - Mycolytic cultures\n - Galactomanna, beta 1,3 glucan\n - Will treat with IV flagyl and PO vanc for concern of C diff\n - Continue Linezolid and Vanc for VRE, coag negative staph and\n Klebsiella\n - Add of /Lip for concern of pancreatitis\n - replete electrolytes aggressively given high output ostomy\n - follow culture data\n ------ Protected Section Addendum Entered By: , MD\n on: 09:53 ------\n" } ]

[ { "category": "Radiology", "chartdate": "2143-10-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1205084, "text": " 5:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess interval change\n Admitting Diagnosis: INFECTED THYROGLOSSAL DUCT CYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p bronch\n REASON FOR THIS EXAMINATION:\n please assess interval change\n ______________________________________________________________________________\n WET READ: SJBj TUE 10:32 PM\n Left lower lobe opacity w air bronchograms new since and may represent\n consolidation or hemorrhage from bronchoscopy. ETT in appropriate location.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after bronchoscopy for\n assessment of the interval change.\n\n Portable AP chest radiograph was reviewed in comparison to prior studies\n obtained the same day earlier on .\n\n The patient has been intubated with the ET tube tip being at the level of the\n clavicular heads approximately 7 cm above the carina. There is new left lower\n lobe opacity that might represent area of atelectasis but aspiration or\n infectious process relatively rapidly developing would be another possibility,\n in particular aspiration. Followup with subsequent radiographs is highly\n recommended. No pneumothorax or appreciable pneumomediastinum seen.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527059, "text": "59 yo M with past medical history of\n dyslipidemia who presented to ED with complaints of exertional\n chest burning x 1 year. He ruled out for MI, but had a positive\n ETT and found to have left main and RCA disease\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA\n POD#1\n Coronary artery bypass graft (CABGx3)\n Assessment:\n Pt A&Ox3, MAE, appropriate. anxious. HR NSR-ST, no ectopy noted.\n Hemodynamically stable, CO>6, CI>2. A and V wires attached. On nitro\n gtt, sbp 90-110. sats 100% on 4L NC lungs clear UL, diminished LL.\n Bowel sounds hypoactive. Pulses palpable. Skin intact, Afebrile. UOP\n adequate. CT draining\n Action:\n Turned ~QH per pt request\n On insulin gtt per C- protocol, QH glucose\n Pt encouraged to cough and deep breath\n Sprio care initiated\n Nitro titrated to maintain sbp<140 per PA \n CT draining thin sero sang fluid\n Sensitivities checked on pacer, left on AAI backup rate of 60\n UOP ~45/h\n Lytes monitored\n O2 titrated to maintain sats>92%\n PA catheter discontinued per PA request\n Response:\n Insulin gtt transitioned off in AM per c- protocol\n Pt coughing and taking deep breaths independently\n IS~ 500cc\n Nitro gtt off, sbp 90-100\n CT draining thin serous fluids, see flowsheet for details\n On 2L NC, sats 94-97%\n UOP remains~ 45cc/h creat 0.6 with AM labs\n Lytes within normal limits with AM labs\n Pt anxious stating\n I feel like I am suffocating because it hurts to\n breathe\n. RN reassured pt that breathing was normal and that all\n numbers were within acceptable parameters. Took time to reassure pt and\n treat pain, repositioned as requested to assist pt comfort with\n breathing\n Plan:\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n Pain treated using:\n -Ketalorac IV\n -Dilaudid IV\n -Percocet PO\n Repositioned QH\n Emotional support provided\n quiet, calm environment,\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports some improvement with pain medications. When not moving or\n deep breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527286, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 96.2 kg\n Allergies/Reactions:\n Tobramycin\n Rash;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: dyslipidemia,GERD,Esophageal Canidida seen on EGD\n 10 years ago, h/o palpitations,h/o tympanic membrane perforation '.\n engineer. quit smoking 3 months ago, rare etoh.s/p appendectomy\n Surgery / Procedure and date: cabg x 3 lima to lad, svg to om+pda,\n ez intubation, kefzol @ 0930, ef 55%,cbp 58',xc 48', neo off pump, act\n 121, chest closure 13:23, 4L crystalloid, no cs or bank blood, uo 285,\n 40 mcq propofol, 10ml ct drainage upon arrival- 140 ml dump with turn,\n no reversals given, 4 twitches with ma 40. extubated at 135, k+calcium\n replaced, sr -st without ectopy. adequate uo. min ct drainage since.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:102\n D:55\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 345 mL\n 24h total out:\n 877 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\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 02:11 AM\n Potassium:\n 4.4 mEq/L\n 02:11 AM\n Chloride:\n 107 mEq/L\n 02:11 AM\n CO2:\n 27 mEq/L\n 02:11 AM\n BUN:\n 13 mg/dL\n 02:11 AM\n Creatinine:\n 0.6 mg/dL\n 02:11 AM\n Glucose:\n 122 mg/dL\n 02:11 AM\n Hematocrit:\n 31.3 %\n 02:11 AM\n Finger Stick Glucose:\n 101\n 07:00 AM\n NURSING NOTE\n 59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage over LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol 120-140mgdL. Turned and repositioned per protocol. Medicated\n with Percocet PO TAB for C/O Incisional pain rated . Stated\n good relief provided with med intervention. Received Reglan 10mg IV for\n c/o nausea this am; total resolution of symptoms after IVP. Family\n visited and updated about POC. OOB to chair 1 assist tolerated effort\n with minimal discomfort.\n PLAN\n Advancing diet to Regular H/H.\n Deline\n Monitor and Control FSBS.\n Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment\n Action:\n Percocet PO, Tylenol PO, Dilaudid IV, Morphine IV, Toradol for pain\n Response:\n Pt reports improvement with pain medications. Able to CDB and use I.S.\n but needing consistent reminder.\n Plan:\n Continue to assess pain and treat using ordered medications. Document\n accordingly\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: CVICU A\n Transferred to: 6\n Date & time of Transfer: 2030hr\n ------ Protected Section ------\n See metavison assessment. Medicated with po dilaudid and in ketoraloc\n for 4/10p aincisional pain.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:32 ------\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527182, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 96.2 kg\n Allergies/Reactions:\n Tobramycin\n Rash;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: dyslipidemia,GERD,Esophageal Canidida seen on EGD\n 10 years ago, h/o palpitations,h/o tympanic membrane perforation '.\n engineer. quit smoking 3 months ago, rare etoh.s/p appendectomy\n Surgery / Procedure and date: cabg x 3 lima to lad, svg to om+pda,\n ez intubation, kefzol @ 0930, ef 55%,cbp 58',xc 48', neo off pump, act\n 121, chest closure 13:23, 4L crystalloid, no cs or bank blood, uo 285,\n 40 mcq propofol, 10ml ct drainage upon arrival- 140 ml dump with turn,\n no reversals given, 4 twitches with ma 40. extubated at 135, k+calcium\n replaced, sr -st without ectopy. adequate uo. min ct drainage since.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:102\n D:55\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 345 mL\n 24h total out:\n 877 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\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 02:11 AM\n Potassium:\n 4.4 mEq/L\n 02:11 AM\n Chloride:\n 107 mEq/L\n 02:11 AM\n CO2:\n 27 mEq/L\n 02:11 AM\n BUN:\n 13 mg/dL\n 02:11 AM\n Creatinine:\n 0.6 mg/dL\n 02:11 AM\n Glucose:\n 122 mg/dL\n 02:11 AM\n Hematocrit:\n 31.3 %\n 02:11 AM\n Finger Stick Glucose:\n 101\n 07:00 AM\n NURSING NOTE\n 59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage over LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol <120. Turned and repositioned per protocol. Medicated with\n Percocet PO TAB for C/O Incisional pain rated . Stated good\n relief provided with med intervention. Received Reglan 10mg IV for c/o\n nausea this am; total resolution of symptoms after IVP.\n PLAN\n Advancing diet to Regular H/H.\n Deline\n Monitor and Control FSBS.\n Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\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": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527277, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 96.2 kg\n Allergies/Reactions:\n Tobramycin\n Rash;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: dyslipidemia,GERD,Esophageal Canidida seen on EGD\n 10 years ago, h/o palpitations,h/o tympanic membrane perforation '.\n engineer. quit smoking 3 months ago, rare etoh.s/p appendectomy\n Surgery / Procedure and date: cabg x 3 lima to lad, svg to om+pda,\n ez intubation, kefzol @ 0930, ef 55%,cbp 58',xc 48', neo off pump, act\n 121, chest closure 13:23, 4L crystalloid, no cs or bank blood, uo 285,\n 40 mcq propofol, 10ml ct drainage upon arrival- 140 ml dump with turn,\n no reversals given, 4 twitches with ma 40. extubated at 135, k+calcium\n replaced, sr -st without ectopy. adequate uo. min ct drainage since.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:102\n D:55\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 345 mL\n 24h total out:\n 877 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\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 02:11 AM\n Potassium:\n 4.4 mEq/L\n 02:11 AM\n Chloride:\n 107 mEq/L\n 02:11 AM\n CO2:\n 27 mEq/L\n 02:11 AM\n BUN:\n 13 mg/dL\n 02:11 AM\n Creatinine:\n 0.6 mg/dL\n 02:11 AM\n Glucose:\n 122 mg/dL\n 02:11 AM\n Hematocrit:\n 31.3 %\n 02:11 AM\n Finger Stick Glucose:\n 101\n 07:00 AM\n NURSING NOTE\n 59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage over LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol 120-140mgdL. Turned and repositioned per protocol. Medicated\n with Percocet PO TAB for C/O Incisional pain rated . Stated\n good relief provided with med intervention. Received Reglan 10mg IV for\n c/o nausea this am; total resolution of symptoms after IVP. Family\n visited and updated about POC. OOB to chair 1 assist tolerated effort\n with minimal discomfort.\n PLAN\n Advancing diet to Regular H/H.\n Deline\n Monitor and Control FSBS.\n Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment\n Action:\n Percocet PO, Tylenol PO, Dilaudid IV, Morphine IV, Toradol for pain\n Response:\n Pt reports improvement with pain medications. Able to CDB and use I.S.\n but needing consistent reminder.\n Plan:\n Continue to assess pain and treat using ordered medications. Document\n accordingly\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: CVICU A\n Transferred to: 6\n Date & time of Transfer: 2030hr\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527278, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 96.2 kg\n Allergies/Reactions:\n Tobramycin\n Rash;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: dyslipidemia,GERD,Esophageal Canidida seen on EGD\n 10 years ago, h/o palpitations,h/o tympanic membrane perforation '.\n engineer. quit smoking 3 months ago, rare etoh.s/p appendectomy\n Surgery / Procedure and date: cabg x 3 lima to lad, svg to om+pda,\n ez intubation, kefzol @ 0930, ef 55%,cbp 58',xc 48', neo off pump, act\n 121, chest closure 13:23, 4L crystalloid, no cs or bank blood, uo 285,\n 40 mcq propofol, 10ml ct drainage upon arrival- 140 ml dump with turn,\n no reversals given, 4 twitches with ma 40. extubated at 135, k+calcium\n replaced, sr -st without ectopy. adequate uo. min ct drainage since.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:102\n D:55\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 345 mL\n 24h total out:\n 877 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\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 02:11 AM\n Potassium:\n 4.4 mEq/L\n 02:11 AM\n Chloride:\n 107 mEq/L\n 02:11 AM\n CO2:\n 27 mEq/L\n 02:11 AM\n BUN:\n 13 mg/dL\n 02:11 AM\n Creatinine:\n 0.6 mg/dL\n 02:11 AM\n Glucose:\n 122 mg/dL\n 02:11 AM\n Hematocrit:\n 31.3 %\n 02:11 AM\n Finger Stick Glucose:\n 101\n 07:00 AM\n NURSING NOTE\n 59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage over LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol 120-140mgdL. Turned and repositioned per protocol. Medicated\n with Percocet PO TAB for C/O Incisional pain rated . Stated\n good relief provided with med intervention. Received Reglan 10mg IV for\n c/o nausea this am; total resolution of symptoms after IVP. Family\n visited and updated about POC. OOB to chair 1 assist tolerated effort\n with minimal discomfort.\n PLAN\n Advancing diet to Regular H/H.\n Deline\n Monitor and Control FSBS.\n Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment\n Action:\n Percocet PO, Tylenol PO, Dilaudid IV, Morphine IV, Toradol for pain\n Response:\n Pt reports improvement with pain medications. Able to CDB and use I.S.\n but needing consistent reminder.\n Plan:\n Continue to assess pain and treat using ordered medications. Document\n accordingly\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: CVICU A\n Transferred to: 6\n Date & time of Transfer: 2030hr\n" }, { "category": "Physician ", "chartdate": "2112-02-25 00:00:00.000", "description": "Intensivist Note", "row_id": 527148, "text": "CVICU\n HPI:\n 59 year old s/p CABG x3 (LIMA>LAD, SVG>OM, SVG>PDA), post-op\n hypertension requiring nitroglycerine (weaned to off) and successfuly\n extubated\n Chief complaint:\n PMHx:\n PMH: Dyslipidemia, GERD, Esophageal seen on EGD 10 yrs ago,\n h/o palpitations, h/o tympanic membrane perforation s/p\n appendectomy\n : Prilosec, ASA 81mg po daily\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 02:05 PM\n PA CATHETER - START 02:10 PM\n INVASIVE VENTILATION - START 02:10 PM\n from or\n ARTERIAL LINE - START 02:10 PM\n CORDIS/INTRODUCER - START 02:10 PM\n NASAL SWAB - At 02:30 PM\n EKG - At 03:00 PM\n EXTUBATION - At 05:35 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n from or\n PA CATHETER - STOP 03:06 AM\n Post operative day:\n POD#1 - cabg x 3 lima to lad, svg to om1 and pda\n Allergies:\n Tobramycin\n Rash;\n Last dose of Antibiotics:\n Cefazolin - 02:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:40 PM\n Hydromorphone (Dilaudid) - 06:00 AM\n Furosemide (Lasix) - 07:02 AM\n Other medications:\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 37.3\nC (99.1\n HR: 98 (73 - 115) bpm\n BP: 102/55(70) {97/52(65) - 121/73(86)} mmHg\n RR: 14 (10 - 20) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 96.2 kg (admission): 83 kg\n Height: 68 Inch\n CVP: 13 (10 - 155) mmHg\n PAP: (32 mmHg) / (17 mmHg)\n CO/CI (Thermodilution): (6.68 L/min) / (3.4 L/min/m2)\n SVR: 659 dynes*sec/cm5\n SV: 68 mL\n SVI: 35 mL/m2\n Total In:\n 7,898 mL\n 338 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,898 mL\n 158 mL\n Blood products:\n Total out:\n 1,503 mL\n 877 mL\n Urine:\n 1,140 mL\n 487 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,395 mL\n -539 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 617 (617 - 617) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.31/49/121/27/-2\n Ve: 6 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\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), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\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 108 K/uL\n 10.8 g/dL\n 122 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 107 mEq/L\n 139 mEq/L\n 31.3 %\n 10.9 K/uL\n [image002.jpg]\n 12:02 PM\n 12:30 PM\n 01:00 PM\n 01:01 PM\n 02:24 PM\n 02:28 PM\n 05:25 PM\n 09:29 PM\n 09:38 PM\n 02:11 AM\n WBC\n 12.9\n 16.0\n 10.9\n Hct\n 32\n 32\n 29.8\n 32\n 33.7\n 30.8\n 31.3\n Plt\n 84\n 112\n 108\n Creatinine\n 0.7\n 0.6\n TCO2\n 27\n 27\n 26\n 25\n 25\n 26\n Glucose\n 109\n 125\n 123\n 107\n 126\n 134\n 122\n Other labs: PT / PTT / INR:12.4/30.0/1.0, Fibrinogen:193 mg/dL, Lactic\n Acid:1.8 mmol/L\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CORONARY ARTERY BYPASS GRAFT\n (CABG)\n Assessment and Plan: 59 year old s/p CABG x3 (LIMA>LAD, SVG>OM,\n SVG>PDA), post-op hypertension requiring nitroglycerine (weaned to off)\n and successfuly extubated\n Neurologic: Neuro checks Q: 4 hr, Pain not well controlled. On percocet\n and ketorolac. Will add tylenol around the clock.\n Cardiovascular: Aspirin, Beta-blocker, HD stable. Will start statin\n today.\n Pulmonary: IS, Get OOB --> chair\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Diurese today 2 L\n Hematology: Serial Hct, Post-op anemia and mild thrombocytopenia.\n Monitor for now.\n Endocrine: RISS, BG well controlled. Goal BG < 150\n Infectious Disease: Periop cefazolin\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:10 PM\n Cordis/Introducer - 02:10 PM\n 16 Gauge - 02:10 PM\n 20 Gauge - 06:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527150, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2112-02-25 00:00:00.000", "description": "ICU Note - CVI", "row_id": 527152, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x3 (LIMA>LAD, SVG>OM, SVG>PDA)\n Ejection Fraction:>55\n Hemoglobin A1c:5.1\n Pre-Op Weight:194 lbs 88 kgs\n Baseline Creatinine:0.7\n PMH: Dyslipidemia, GERD, Esophageal seen on EGD 10 yrs ago,\n h/o palpitations, h/o tympanic membrane perforation s/p\n appendectomy\n : Prilosec ASA 81mg po daily\n Current medications:\n 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6.\n CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Dextrose 50% 9. Docusate Sodium 10. HYDROmorphone (Dilaudid) 11.\n HYDROmorphone (Dilaudid) 12. Insulin\n 13. Ketorolac 14. Magnesium Sulfate 15. Metoprolol Tartrate 16.\n Metoprolol Tartrate 17. Metoclopramide\n 18. Milk of Magnesia 19. Morphine Sulfate 20. Nitroglycerin 21.\n Omeprazole 22. Oxycodone-Acetaminophen\n 23. Phenylephrine 24. Potassium Chloride 25. Sodium Chloride 0.9% Flush\n PMHx: dyslipidemia, GERD, s/p appy\n 24 Hour Events:\n OR RECEIVED - At 02:05 PM\n PA CATHETER - START 02:10 PM\n INVASIVE VENTILATION - START 02:10 PM\n from or\n ARTERIAL LINE - START 02:10 PM\n CORDIS/INTRODUCER - START 02:10 PM\n NASAL SWAB - At 02:30 PM\n EKG - At 03:00 PM\n EXTUBATION - At 05:35 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n from or\n PA CATHETER - STOP 03:06 AM\n Post operative day:\n POD#1 - cabg x 3 lima to lad, svg to om1 and pda\n Allergies:\n Tobramycin\n Rash;\n Last dose of Antibiotics:\n Cefazolin - 02:00 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Morphine Sulfate - 06:40 PM\n Hydromorphone (Dilaudid) - 06:00 AM\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 37.3\nC (99.1\n HR: 98 (73 - 115) bpm\n BP: 105/59(73) {97/52(65) - 121/73(86)} mmHg\n RR: 12 (10 - 20) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.2 kg (admission): 83 kg\n Height: 68 Inch\n CVP: 13 (10 - 155) mmHg\n PAP: (32 mmHg) / (17 mmHg)\n CO/CI (Thermodilution): (6.68 L/min) / (3.4 L/min/m2)\n SVR: 754 dynes*sec/cm5\n SV: 66 mL\n SVI: 34 mL/m2\n Total In:\n 7,898 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,898 mL\n 133 mL\n Blood products:\n Total out:\n 1,503 mL\n 642 mL\n Urine:\n 1,140 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,395 mL\n -509 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 617 (617 - 617) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 93%\n ABG: 7.31/49/121/27/-2\n Ve: 6 L/min\n PaO2 / FiO2: 303\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 108 K/uL\n 10.8 g/dL\n 122 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 107 mEq/L\n 139 mEq/L\n 31.3 %\n 10.9 K/uL\n [image002.jpg]\n 12:02 PM\n 12:30 PM\n 01:00 PM\n 01:01 PM\n 02:24 PM\n 02:28 PM\n 05:25 PM\n 09:29 PM\n 09:38 PM\n 02:11 AM\n WBC\n 12.9\n 16.0\n 10.9\n Hct\n 32\n 32\n 29.8\n 32\n 33.7\n 30.8\n 31.3\n Plt\n 84\n 112\n 108\n Creatinine\n 0.7\n 0.6\n TCO2\n 27\n 27\n 26\n 25\n 25\n 26\n Glucose\n 109\n 125\n 123\n 107\n 126\n 134\n 122\n Other labs: PT / PTT / INR:12.4/30.0/1.0, Fibrinogen:193 mg/dL, Lactic\n Acid:1.8 mmol/L\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CORONARY ARTERY BYPASS GRAFT\n (CABG)\n Assessment and Plan: s/p CABGx3 now extubated and ready for transfer to\n the floor\n Neurologic: Neuro checks Q: 4 hr, Pain poorly controlled on dilaudid,\n will add Tylenol around the clock for better control\n Cardiovascular: Aspirin, Beta-blocker, add statin today.\n Pulmonary: IS, cough and deep breath, OOB to chair\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO, Lasix started today\n Hematology: stable anemia\n Endocrine: RISS, Insulin drip, Lantus (R), 10 units of lantus and\n sliding scale insulin for goal BG < 150\n Infectious Disease: cefazolin for periop antibiotics, no evidence of\n infection\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition: heart healthy\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Arterial Line - 02:10 PM\n Cordis/Introducer - 02:10 PM\n 16 Gauge - 02:10 PM\n 20 Gauge - 06:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527156, "text": "59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease.\n CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage ove LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose.\n Turned ~QH per pt request\n On insulin gtt per C- protocol, QH glucose\n Pt encouraged to cough and deep breath\n Sprio care initiated\n Nitro titrated to maintain sbp<140 per PA \n CT draining thin sero sang fluid\n Sensitivities checked on pacer, left on AAI backup rate of 60 due to\n tachy HR\n UOP ~45/h\n Lytes monitored\n O2 titrated to maintain sats>92%\n PA catheter discontinued per PA request\n Insulin gtt transitioned off in AM per c- protocol\n Pt coughing and taking deep breaths independently\n IS~ 500cc\n Nitro gtt off, sbp 90-100\n CT draining thin serous fluids, see flowsheet for details\n On 2L NC, sats 94-97%\n UOP remains~ 45cc/h creat 0.6 with AM labs\n 20\n peripheral in L arm this AM\n Lytes within normal limits with AM labs\n Pt anxious stating\n I feel like I am suffocating because it hurts to\n breathe\n. RN reassured pt that his breathing was normal and that all\n numbers were within acceptable parameters. Took time to reassure pt and\n treat pain, repositioned as requested to assist pt comfort with\n breathing\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain treated using:\n -Ketalorac IV\n -Dilaudid IV\n -Percocet PO\n Repositioned QH\n Emotional support provided\n quiet, calm environment,\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527160, "text": "59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage ove LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol <120. Turned and repositioned per protocol. Medicated with\n Percocet PO TAB for C/O Incisional pain rated . Stated good\n relief provided with med intervention.\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527162, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 96.2 kg\n Allergies/Reactions:\n Tobramycin\n Rash;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: dyslipidemia,GERD,Esophageal Canidida seen on EGD\n 10 years ago, h/o palpitations,h/o tympanic membrane perforation '.\n engineer. quit smoking 3 months ago, rare etoh.s/p appendectomy\n Surgery / Procedure and date: cabg x 3 lima to lad, svg to om+pda,\n ez intubation, kefzol @ 0930, ef 55%,cbp 58',xc 48', neo off pump, act\n 121, chest closure 13:23, 4L crystalloid, no cs or bank blood, uo 285,\n 40 mcq propofol, 10ml ct drainage upon arrival- 140 ml dump with turn,\n no reversals given, 4 twitches with ma 40. extubated at 135, k+calcium\n replaced, sr -st without ectopy. adequate uo. min ct drainage since.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:63\n Temperature:\n 99.1\n Arterial BP:\n S:102\n D:55\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 345 mL\n 24h total out:\n 877 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\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 02:11 AM\n Potassium:\n 4.4 mEq/L\n 02:11 AM\n Chloride:\n 107 mEq/L\n 02:11 AM\n CO2:\n 27 mEq/L\n 02:11 AM\n BUN:\n 13 mg/dL\n 02:11 AM\n Creatinine:\n 0.6 mg/dL\n 02:11 AM\n Glucose:\n 122 mg/dL\n 02:11 AM\n Hematocrit:\n 31.3 %\n 02:11 AM\n Finger Stick Glucose:\n 101\n 07:00 AM\n NURSING NOTE\n 59 yo M with past medical history of dyslipidemia who presented to ED\n with complaints of exertional chest burning x 1 year. He ruled out for\n MI, but had a positive ETT and found to have left main and RCA\n disease. CCATH Results as follows:\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA.\n CABGx3 LIMA\n LAD, SVG to OM\n PDA\n POD#1\n Afebrile. A&Ox3. MAE\ns with good ROM. Verbal response is appropriate.\n Mildly anxious, reassurances given along with explanation of POC. O2\n sats 100% on 2L NC. LSC with dim bases bilat. CT draining minimal thin\n serosanguinous DRG.\n ST per tele 100\ns, PAC runs this am; on Lopressor PO 25mg. AV wires\n attached, connected to temp pacer.\n SBP90-110mmHg; cuff pressures correlate. Tolerating PO meds, sips.\n Distant hypoactive BS auscultated 4 Q\n Easily palpable PP bilaterally; ACE bandage ove LLE. Skin otherwise\n intact. Foley catheter draining clear yellow urine U/O 50-60cc/hr with\n improved diuresis post Lasix x1 dose. FSBS Q2hr after CVCIU transition\n protocol <120. Turned and repositioned per protocol. Medicated with\n Percocet PO TAB for C/O Incisional pain rated . Stated good\n relief provided with med intervention.\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\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": "2112-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527031, "text": "59 year old male with 1 year history of chest burning - r/o mi,\n +ett, cath 3 vessel cad with left main,\n Coronary artery bypass graft (CABG\n Assessment:\n Sr-st without atrial / ventricular arrtyhymias, sbp >100 on\n .3 neo out of or, ci>2., ct drainage- until turn 140ml,hct 33.\n k3.7, glucose 126, warm and dry, pp palp\n Bs diminished bibasilar, abg good on 50%, o2 sat>95%\n Awoke neuro intact\n Good uo\n Action:\n Lopressor 5 mg x 110\ns, received po lopressor at\n 2200, neo dc\nd. ntg initiated when awoke- presently at 1 , ct\n drainage , 40 meq kcl given, insulin gtt started at 2230 due to glucose\n 134, lr #4 liter infusing\n Extubated at 1735 4 twitches on 40 ma , no reversals given.\n Taking sips of clears\n Uo decreasing\n Response:\n Sr 90\ns without ectopy, sbp 100\ns, repeat k4.4, hct 30.8,\n Is 500 with much encouragement, tc+db with results of 2200\n abg, 02 sats >95%\n Calm\n Uo 35 ml at 2200\n Plan:\n Monitor comfort, hr and rythym, sbp-wean ntg as tolerated,\n ci, ct drainage, pp, dsgs, resp status-pulm toilet, neuro status,\n i+o-uo, labs . as per orders.\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527033, "text": "59 yo M with past medical history of\n dyslipidemia who presented to ED with complaints of exertional\n chest burning x 1 year. He ruled out for MI, but had a positive\n ETT and found to have left main and RCA disease\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA\n POD#1\n Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2112-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527008, "text": "59 year old male with 1 year history of r/o mi, +ett, cath 3 vessel\n cad with left main,\n Coronary artery bypass graft (CABG\n Assessment:\n Sr-st without atrial / ventricular arrtyhymias, sbp >100 on .3 mcq neo\n out of or,\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2112-02-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526990, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective; Comments: s/p cabg\n Tube Type\n ETT:\n Position: 22 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: 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: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Weaned to cpap of 5 and ps 5 50% tolerating well.\n Extubate per protocol.\n Reason for continuing current ventilatory support:\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527102, "text": "59 yo M with past medical history of\n dyslipidemia who presented to ED with complaints of exertional\n chest burning x 1 year. He ruled out for MI, but had a positive\n ETT and found to have left main and RCA disease\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA\n POD#1\n Coronary artery bypass graft (CABGx3)\n Assessment:\n Pt A&Ox3, MAE, appropriate. anxious. HR NSR-ST, no ectopy noted.\n Hemodynamically stable, CO>6, CI>2. A and V wires attached. On nitro\n gtt, sbp 90-110. sats 100% on 4L NC lungs clear UL, diminished LL.\n Bowel sounds hypoactive. Pulses palpable. Skin intact, Afebrile. UOP\n adequate. CT draining\n Action:\n Turned ~QH per pt request\n On insulin gtt per C- protocol, QH glucose\n Pt encouraged to cough and deep breath\n Sprio care initiated\n Nitro titrated to maintain sbp<140 per PA \n CT draining thin sero sang fluid\n Sensitivities checked on pacer, left on AAI backup rate of 60 due to\n tachy HR\n UOP ~45/h\n Lytes monitored\n O2 titrated to maintain sats>92%\n PA catheter discontinued per PA request\n Response:\n Insulin gtt transitioned off in AM per c- protocol\n Pt coughing and taking deep breaths independently\n IS~ 500cc\n Nitro gtt off, sbp 90-100\n CT draining thin serous fluids, see flowsheet for details\n On 2L NC, sats 94-97%\n UOP remains~ 45cc/h creat 0.6 with AM labs\n 20\n peripheral in L arm this AM\n Lytes within normal limits with AM labs\n Pt anxious stating\n I feel like I am suffocating because it hurts to\n breathe\n. RN reassured pt that his breathing was normal and that all\n numbers were within acceptable parameters. Took time to reassure pt and\n treat pain, repositioned as requested to assist pt comfort with\n breathing\n Plan:\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n Pain treated using:\n -Ketalorac IV\n -Dilaudid IV\n -Percocet PO\n Repositioned QH\n Emotional support provided\n quiet, calm environment,\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\n" }, { "category": "Nursing", "chartdate": "2112-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527103, "text": "59 yo M with past medical history of\n dyslipidemia who presented to ED with complaints of exertional\n chest burning x 1 year. He ruled out for MI, but had a positive\n ETT and found to have left main and RCA disease\n LVG: normal LV function\n Right dominant system\n LM:distal 60% lesion\n LAD:minimal disease\n LCx:minimal disease\n RCA:long segment mid disease with stenoses to 80%; collaterals\n from LCA\n POD#1\n Coronary artery bypass graft (CABGx3)\n Assessment:\n Pt A&Ox3, MAE, appropriate. anxious. HR NSR-ST, no ectopy noted.\n Hemodynamically stable, CO>6, CI>2. A and V wires attached. On nitro\n gtt, sbp 90-110. sats 100% on 4L NC lungs clear UL, diminished LL.\n Bowel sounds hypoactive. Pulses palpable. Skin intact, Afebrile. UOP\n adequate. CT draining\n Action:\n Turned ~QH per pt request\n On insulin gtt per C- protocol, QH glucose\n Pt encouraged to cough and deep breath\n Sprio care initiated\n Nitro titrated to maintain sbp<140 per PA \n CT draining thin sero sang fluid\n Sensitivities checked on pacer, left on AAI backup rate of 60 due to\n tachy HR\n UOP ~45/h\n Lytes monitored\n O2 titrated to maintain sats>92%\n PA catheter discontinued per PA request\n Response:\n Insulin gtt transitioned off in AM per c- protocol\n Pt coughing and taking deep breaths independently\n IS~ 500cc\n Nitro gtt off, sbp 90-100\n CT draining thin serous fluids, see flowsheet for details\n On 2L NC, sats 94-97%\n UOP remains~ 45cc/h creat 0.6 with AM labs\n 20\n peripheral in L arm this AM\n Lytes within normal limits with AM labs\n Pt anxious stating\n I feel like I am suffocating because it hurts to\n breathe\n. RN reassured pt that his breathing was normal and that all\n numbers were within acceptable parameters. Took time to reassure pt and\n treat pain, repositioned as requested to assist pt comfort with\n breathing\n Plan:\n Increase diet and activity as tolerated, deline. Transfer to 6\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt states pain on assessment. Pt 59 years old, anxious regarding\n heart surgery and his condition\n Action:\n Pain treated using:\n -Ketalorac IV\n -Dilaudid IV\n -Percocet PO\n Repositioned QH\n Emotional support provided\n quiet, calm environment,\n time with pt to answer questions as reassure regarding his health\n status and plan of care\n Response:\n Pt reports improvement with pain medications. When not moving or deep\n breathing pain , when deep breathing and repositioning pain\n reported \n Pt seems more relaxed with RN in the room, states liking the continual\n reassurance of health status. Asks questions regarding plan of care,\n and thanks staff for time and explanations\n Plan:\n Continue to assess pain and treat using ordered medications, provide pt\n with explanation of plan of care, take time to reassure pt, and answer\n questions\n" }, { "category": "Physician ", "chartdate": "2112-02-25 00:00:00.000", "description": "ICU Note - CVI", "row_id": 527096, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x3 (LIMA>LAD, SVG>OM, SVG>PDA)\n Ejection Fraction:>55\n Hemoglobin A1c:5.1\n Pre-Op Weight:194 lbs 88 kgs\n Baseline Creatinine:0.7\n PMH: Dyslipidemia, GERD, Esophageal seen on EGD 10 yrs ago,\n h/o palpitations, h/o tympanic membrane perforation s/p\n appendectomy\n : Prilosec ASA 81mg po daily\n Current medications:\n 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6.\n CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Dextrose 50% 9. Docusate Sodium 10. HYDROmorphone (Dilaudid) 11.\n HYDROmorphone (Dilaudid) 12. Insulin\n 13. Ketorolac 14. Magnesium Sulfate 15. Metoprolol Tartrate 16.\n Metoprolol Tartrate 17. Metoclopramide\n 18. Milk of Magnesia 19. Morphine Sulfate 20. Nitroglycerin 21.\n Omeprazole 22. Oxycodone-Acetaminophen\n 23. Phenylephrine 24. Potassium Chloride 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 02:05 PM\n PA CATHETER - START 02:10 PM\n INVASIVE VENTILATION - START 02:10 PM\n from or\n ARTERIAL LINE - START 02:10 PM\n CORDIS/INTRODUCER - START 02:10 PM\n NASAL SWAB - At 02:30 PM\n EKG - At 03:00 PM\n EXTUBATION - At 05:35 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n from or\n PA CATHETER - STOP 03:06 AM\n Post operative day:\n POD#1 - cabg x 3 lima to lad, svg to om1 and pda\n Allergies:\n Tobramycin\n Rash;\n Last dose of Antibiotics:\n Cefazolin - 02:00 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Morphine Sulfate - 06:40 PM\n Hydromorphone (Dilaudid) - 06:00 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 37.3\nC (99.1\n HR: 98 (73 - 115) bpm\n BP: 105/59(73) {97/52(65) - 121/73(86)} mmHg\n RR: 12 (10 - 20) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.2 kg (admission): 83 kg\n Height: 68 Inch\n CVP: 13 (10 - 155) mmHg\n PAP: (32 mmHg) / (17 mmHg)\n CO/CI (Thermodilution): (6.68 L/min) / (3.4 L/min/m2)\n SVR: 754 dynes*sec/cm5\n SV: 66 mL\n SVI: 34 mL/m2\n Total In:\n 7,898 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,898 mL\n 133 mL\n Blood products:\n Total out:\n 1,503 mL\n 642 mL\n Urine:\n 1,140 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,395 mL\n -509 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 617 (617 - 617) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 11 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 93%\n ABG: 7.31/49/121/27/-2\n Ve: 6 L/min\n PaO2 / FiO2: 303\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 108 K/uL\n 10.8 g/dL\n 122 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 107 mEq/L\n 139 mEq/L\n 31.3 %\n 10.9 K/uL\n [image002.jpg]\n 12:02 PM\n 12:30 PM\n 01:00 PM\n 01:01 PM\n 02:24 PM\n 02:28 PM\n 05:25 PM\n 09:29 PM\n 09:38 PM\n 02:11 AM\n WBC\n 12.9\n 16.0\n 10.9\n Hct\n 32\n 32\n 29.8\n 32\n 33.7\n 30.8\n 31.3\n Plt\n 84\n 112\n 108\n Creatinine\n 0.7\n 0.6\n TCO2\n 27\n 27\n 26\n 25\n 25\n 26\n Glucose\n 109\n 125\n 123\n 107\n 126\n 134\n 122\n Other labs: PT / PTT / INR:12.4/30.0/1.0, Fibrinogen:193 mg/dL, Lactic\n Acid:1.8 mmol/L\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CORONARY ARTERY BYPASS GRAFT\n (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, dilaudid and tylenol\n prn effective\n Cardiovascular: Aspirin, Beta-blocker, Statins,\n Pulmonary: IS, cough and deep breath, OOB to chair\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO,\n Hematology: stable anemia\n Endocrine: RISS, Insulin drip, Lantus (R),\n units of lantus and\n sliding scale insulin for goal BG < 150\n Infectious Disease: .////for periop antibiotics, ???- no evidence of\n infection\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Arterial Line - 02:10 PM\n Cordis/Introducer - 02:10 PM\n 16 Gauge - 02:10 PM\n 20 Gauge - 06:00 AM\n Prophylaxis:\n DVT:\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" }, { "category": "Echo", "chartdate": "2112-02-24 00:00:00.000", "description": "Report", "row_id": 97351, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 12:26\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in\nthe body of the LAA. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Normal mitral valve\nsupporting structures.\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 TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. Left\nventricular wall thicknesses and cavity size are normal. Right ventricular\nchamber size and free wall motion are normal. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no pericardial effusion.\n\nPOST-CPB:\n\n1. Preserved -ventricular systolci function.\n\n2, No change in valve structure and function\n\n3. Intact aorta\n\n\n" }, { "category": "ECG", "chartdate": "2112-02-24 00:00:00.000", "description": "Report", "row_id": 287747, "text": "Sinus rhythm. Consider inferior myocardial infarction of indeterminate age,\nalthough tracing is otherwise, within normal limits and clinical correlation is\nsuggested. Since the previous tracing of inferior lead Q waves are\nmore prominent and modest inferior T wave changes are seen.\n\n" }, { "category": "Radiology", "chartdate": "2112-02-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1126054, "text": " 2:33 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with s/p CABG - pleaes with results if\n there is concern\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man status post CABG.\n\n COMPARISON: Chest radiograph from at 1 p.m.\n\n SINGLE FRONTAL CHEST RADIOGRAPH:\n\n The lungs have lung volumes. Minimal left lower lobe atelectasis but no\n pneumothorax. The cardiomediastinal silhouette, hilar contours, and pleural\n surfaces are normal. Swan-Ganz catheter, ET tube, NG tube, and a mediastinal\n and left chest tube are in good position.\n\n IMPRESSION:\n No pneumothorax or pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-02-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126386, "text": " 7:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal ? ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p ct removal ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man status post CABG.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL CHEST RADIOGRAPH:\n\n Patient has low lung volumes with increasing opacity in the left lower lobe.\n The cardiomediastinal silhouette and hilar contours are normal. There is a\n small left pleural effusion. No pneumothorax is present.\n\n IMPRESSION:\n\n No pneumothorax. Worsening left lower lobe atelectasis with small left\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-02-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1126758, "text": " 7:16 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusions, atx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate effusions, atx\n ______________________________________________________________________________\n WET READ: DLrc SUN 8:41 PM\n Stable left sided pleural effusion and associated left lower lobe atelectasis.\n No evidence of pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n FINDINGS: There has been previous median sternotomy and coronary artery\n bypass surgery. Cardiomediastinal contours are stable in appearance during\n the postoperative period. Improving atelectasis at both lung bases with\n residual atelectasis, worse on the left than the right. Small pleural\n effusions are also demonstrated with interval decrease on the left. On the\n lateral view, retrosternal gas collections are probably due to the recent\n sternotomy.\n\n IMPRESSION: Improving bibasilar atelectasis and small effusions, left greater\n than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-02-24 00:00:00.000", "description": "O CHEST (PORTABLE AP) IN O.R.", "row_id": 1126047, "text": " 1:42 PM\n CHEST (PORTABLE AP) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n Reason: BROKEN TIP OF NEEDLE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male inside operating room with a broken tip of the\n needle.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL CHEST RADIOGRAPH:\n\n The left costophrenic angle was not imaged on the current study. An endoscope\n terminates in the mid to distal esophagus. A Swan-Ganz catheter terminates in\n the pulmonary artery. An ET tube terminates 7 cm above the carina. No needle\n is noted on the current study, although the fragment could be too small to\n detect. Visible lungs are well expanded and clear. A clip is noted in the\n upper abdomen 5 cm below the lower sternal wire.\n\n IMPRESSION:\n\n No needle in the field of view. A fragment could be too small to detect given\n the limitations of bedside radiography. Conventional views recommended when\n feasible.\n\n These findings were communicated to the operating room at the time of initial\n review.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2173-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 965236, "text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with worsening b/l consolidations & ? R lung abscess.\n\n REASON FOR THIS EXAMINATION:\n assess for interval change in infiltrate, and he pulled on his NG tube, assess\n for placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening bilateral lower lobe consolidations.\n\n CHEST, ONE VIEW: Comparison with . Nasogastric tube remains in\n place. Pulmonary edema, slightly worse. Bilateral lower lobe consolidation.\n Unchanged appearance of loculated air in right lung base. Cardiac,\n mediastinal, and hilar countours are similar in appearance.\n\n IMPRESSION: Continued bilateral lower lobe consolidations and slightly worse\n pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2173-07-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 965261, "text": " 10:29 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Pt had a left sided picc line placed,53cm,and needs tip conf\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with worsening b/l consolidations & ? R lung abscess who\n needs picc line for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,53cm,and needs tip confirmation,please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC for IV antibiotics.\n\n CHEST, ONE VIEW: Comparison with examination of same day, 1.5 hours prior.\n New left PICC with tip in the distal SVC. No pneumothorax. The remainder of\n the examination is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2173-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 965070, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? progression of cxr findings?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with worsening b/l consolidations & ? R lung abscess.\n REASON FOR THIS EXAMINATION:\n ? progression of cxr findings?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old man with worsening bilateral consolidations and question\n of right lung abscess.\n\n COMPARISON: and .\n\n CHEST AP: Cardiac, mediastinal and hilar contours are stable. There\n continued to be bilateral perihilar opacities as well as bilateral lower lobe\n consolidation and pleural effusions. Rounded focus of air overlying the right\n lower lung is again noted. Nasogastric tube is in unchanged position.\n\n IMPRESSION: Similar radiographic appearance of the chest with findings\n consistent with lower lobe pneumonia and superimposed CHF. Stable right lower\n unusual collection gas which may represent a pneumatocele.\n\n" }, { "category": "Radiology", "chartdate": "2173-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 964829, "text": " 5:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with fever, tachy\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n WET READ: ACKe MON 5:39 PM\n bilateral airspace opacities likely reflect aspiration/aspiration pneumonia.\n 9mm nodular opacity LUL will need further characterization with PA and\n lateral, which can be done at time of followup for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and tachycardia.\n\n CHEST, ONE VIEW: No prior for comparison. Airspace opacities, large and\n confluent over the right lower and left lower lung zones, but also seen less\n prominently in the upper and mid lung zones, likely represents consolidation\n most likely from aspiration, given the largely gravity-dependent distribution.\n A 9-mm partially well-demarcated ovoid lesion in the left lung apex is not\n completely characterized on this study. Cardiac contour is top normal in\n size. Pulmonary hila are full, but there is no overt evidence of CHF. No\n pneumothorax or pleural effusion. Osseous structures are grossly normal.\n\n IMPRESSION:\n 1. Multifocal airspace opacities, likely representing multifocal pneumonia,\n possibly due to aspiration given mostly dependent distribution. Followup\n radiograph recommended in six weeks to document resolution.\n 2. 9-mm nodular opacity in the left upper lung zone, which may be due to the\n acute pneumonic process but incidental lung cancer is also possible. If\n persistent at time of followup CXR, CT would be indicated.\n\n Preliminary findings relayed to the ED dashboard at time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2173-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 964982, "text": " 1:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with fever,poor po intake, new NG placement\n\n REASON FOR THIS EXAMINATION:\n NG placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of fever, poor oral intake and NG tube placement.\n\n NG tube is in region of mid body of stomach. Compared with the previous film\n of , there is in new relatively large area of air space\n consolidation in the left lower lobe, partly obscuring the left hemidiaphragm\n in addition to the patchy opacities previously noted in the left mid and lower\n zones. In addition, there is increased confluent opacity at the right lung\n base with possible small right pleural effusion and an air fluid level is now\n present at the right lung base, difficult to localize in this single frontal\n view in relation to the obscured right hemidiaphragm. The possibility of new\n lung abscess is raised. Focal opacities in both apical regions, possibly\n calcified foci. Linear atelectasis left upper lobe.\n\n IMPRESSION: Worsening of previously demonstrated bilateral lower zone\n pulmonary consolidations with new area of confluent consolidation in left\n lower lobe and increased consolidation at right lung base with probable small\n effusion and lung abscess to account for for new focal air- fluid level in\n this location. Correlate clinically and with further followup/PA and lateral\n films if possible or CT scan.\n\n Findings discussed by telephone with Dr. .\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-22 00:00:00.000", "description": "Report", "row_id": 1348747, "text": "Resp. Care Note\nPt followed for Q6 Atrovent nebs as ordered. Rx'd x 2. BS with coarse exp rhonchi. Cont as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2173-07-22 00:00:00.000", "description": "Report", "row_id": 1348745, "text": "MICU Nursing Progress 1900-0700\n\nCode: DNR/DNI\nAllergies: NKDA\n\nUneventful shift.\n\nPt is 81 year old male admitted from nursing home with hypoxia and fever. History of AFIB with RVR, Parkinsons, dementia, and schizophrenia. CXR revealed likely aspiration pna. Transferred to CCU then MICU for further management.\n\nNeuro: Pt unresponsive and nonverbal at baseline, pt known to be agitated and combative, however not requiring any PRN meds. Pt responsive to pain, but not following commands. Remains in bilateral soft wrist restraints for safety, will grab for lines, tubes, staff if unrestrained.\n\nCV: Pt hemodynamically stable, HR AFIB 80-90s with occasional PVC (rate controlled with dig). NBP 125-152/50-60. Crit stable. PIV x 2.\n\nResp: RR 20-40 with sats >97% on 4L NC. Lung sounds coarse to clear in apices, diminished in bases. Attempted to NT suctioned however pt unable to tolerate procedure. Cough/gag intact.\n\nGI: BS x 4, no stool this shift. TF running at goal rate of 40cc/hr with minimal residual via NGT. Tube patent, placement checked.\n\nGU: Foley patent and draining minimal amounts of clear, yellow urine. AM labs pending, will replete as ordered.\n\nSkin: Ecchymotic areas to bilateral wrists from pt pulling against restrains. Small reddened area noted to coccyx, barrier cream applied with each turn.\n\nID: Tmax 99.3 AX, continues on ABX for aspiration pna. Vanco trough 16.4.\n\nSocial: No contact from family overnight. MD to talk to HCP today regarding plan of care for pt.\n\nPlan:\nlikely C/O to floor\nPRN medication for agitation/safety\npulmonary toileting as tolerated\ncontact HCP re: plan of care\nskin care ? air bed\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2173-07-22 00:00:00.000", "description": "Report", "row_id": 1348746, "text": "Nursing Progress Note:\n\nNeuro: Pt was very agitated in morning, able to scoot himself down in bed enough to pull NG tube out halfway despite being restrained. He mumbles incoherently, does not follow commands, localizes pain, MAE with normal strength (quite strong!). He opens his eyes only a slit. Pt. initially had only wrist restraints but mittens were added to prevent pulling lines and tubes. Pt. was given 0.5mg Ativan twice in morning (once to aid in PICC placement) and slept for most of the day, team would like Zyprexa used rather than Ativan, 2.5mg Zyprexa given in afternoon.\n\nCV: HR 90s a-fib with frequent ventricular ectopy, NBP 130s-150s/ 30s-40s, Diltiazem added back to meds. L PICC placed and is OK to use. Pt. has good color,temp, and capillary refill to upper ext.\n\nResp: RR in 30s-40s (baseline for pt.),02 sats >95% on room air. Lungs are clear to course, R more diminished, crackles in L base. Pt. also has upper airway secretions which he is unable to clear with cough.\n\nGI: Pt. pulled NG tube halway out twice after which it was pushed back in. Tube feeds stopped, chest X-ray confirmed that it would be OK to use if it was a few cm. further out than it was originally (per intern) Tube placement sounds good by auscultation. Tube feeds restarted at 40cc/hour with minimal residuals. BSX4, no BM on shift.\n\nGU: UO 30-150cc/hour via foley.\n\nSkin: Small area of breakdown on coccyx, Aloe vesta applied. Pt. difficult to turn as he squirms around and ends up supine.\n\nSocial: Legal guardian (court appointed) contact by MD and\npt. is to be sent to floor with further decisions to be made later.\n" }, { "category": "Nursing/other", "chartdate": "2173-07-20 00:00:00.000", "description": "Report", "row_id": 1348740, "text": "Resp Care\n\nPt started on atrovent nebs; BS generally clear with occ rhonchi\n" }, { "category": "Nursing/other", "chartdate": "2173-07-20 00:00:00.000", "description": "Report", "row_id": 1348741, "text": "CCU Nursing Addendum\nO: Foley cath placement check, flushed w/ NSS. Position good. U/O cont <20cc/hr, despite 500cc fluid bolus. Dr. aware.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-21 00:00:00.000", "description": "Report", "row_id": 1348742, "text": "Resp Care\nPT given Atrovent nebs Q6Hrs. BS mostly clear/diminished bilaterally. Currently on 4L NC, Spo2=96%.\n" }, { "category": "Nursing/other", "chartdate": "2173-07-21 00:00:00.000", "description": "Report", "row_id": 1348743, "text": "Nursing Progress Note 1900-0700\nS: Mumbles incomprehensible sounds, nonverbal @ baseline\n\nO: Please see carevue for complete objective data.\n\n81yo male admitted from nursing home for hypoxia r/t poss asp PNA, febrile to 102.0 rectally and found to be in rapid A-fib with rate in the 130's. Treated c abx, IV dilt and IVF and transferred to CCU as MICU Border.\n\nPMH includes Parkinson's, schizophrenia, dementia, osteomyelitis, and AF. Pt in DNR/DNI.\n\nID: remains Febrile and rec'ing tylenol ATC. on Vanco and Zosyn. Blood and urine cx's pending.\n\nNeuro: Oriented x 0, MAE. Soft wrist restraints applied to maintain line/tube integrity. lethargic, but becomes combative and agitated with cares and stimulation. Managed with ativan and zyprexa. Requires close observation.\n\nCV: A-fib, rate 70-90's c ocas PVC's, taking po dilt. SBP 90-110's. AM labs pnding.\n\nResp: Lungs clr c nonprod cough. Sats 93-100 on 4L nc. Tachypneic up to 40's.\n\nGI/GU: NGT placed in R nare . TF started and currently @ 30cc/hr, minimal residuals. No BM. Foley patent and draining cloudy amber concentrated urine. IVF @ 100cc/hr for total of 2L, 2nd liter hanging. UO low ~ 10-20cc/hr. team aware.\n\nSkin: Intact, small reddened area on coccyx. Aloe vesta applied and turned Q2h.\n\nP: Cont to monitor I&O's. Advance TF as tol, follow up c labs. Keep restrained and ?needs sitter if called out to floor. Cont abx therapy. Emtionally support pt.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-21 00:00:00.000", "description": "Report", "row_id": 1348744, "text": "CCU NSG NOTE: ALT IN RESP/PNUEMONIA\nO: For complete VS see CCU flow sheet.\nThis 81y old male who lives in nsg home with pmh of dementia, skizophrenia, parkinson, COPD and afib was transfered from nsg home with fever and 02 sat in th 80s. He was combative on arrival, cachetic appearing. He had afib in 140s. Xray showed -lateral infiltrate and probable asp pnuemonia. He contd febrile.\nID: T-max 99.8R. He conts on vanco and zosyn with vanco trough due before next dose. WBCs 14.2 (15).\nCV: He remains in afib with rate 70-80s with frequent PVCs. He is rate controlled with dig. He had been on dilt but it was d/c this am. K+ was 3.0 and he was repleted with total of 60 meq. Phos is 1.9 and he is now receiving 30mm kphos.\nRESP: RR 36-45. he is on 4L NP with sats usually 97-99%, however he occassionally drops to the high 80s. he was suctioned orally for thich bloody sputum. Breath sounds are rhonchorous. He has strong cough.\nRENAL: Urine output continues poor-2-15cc/hr of consentrated urine. IVF was d/c. he is ~2800cc pos for the day and >7 liters pos LOS.\nGI: Tube feed of nuetrin pulmonary is at goal of 40cc/hr with minimal residuals. He had smeary stool that was G-.\nSKIN: Pt has multiple areas of eccymosis. He has small reddened spot over body coccyx that is not yet broken. Other pressure spots are not reddened. We attempt to turn him Q 2, but he squirms around to his back. His mouth has numerous missing and broken teeth. Mough care can be done, though he fights.\nMS: Pt is non-vebal and can be very aggitated and combative. He follows no commands. he can receive ativan .5 Q8 and olanzapine 2.5 . He last received olanzapine at 0800. He is restained and will pull hard on restraint--right arm is eccymotic for this.\nA: Requires pulmonary hygiene/pt unable to cooperate with care\nP: Cont to attempt to change position. ? pt may need air bed. Monitor for tolerating tube feeds. Monitor for fever. Continue with suctioning prn and mouth care.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-07-20 00:00:00.000", "description": "Report", "row_id": 1348738, "text": "Nursing Progress Note -0700\nS: Non verbal, groans and mumbles.\n\nO: Please see carevue for complete objective data.\n\n81 yo male, DNR/DNI, brought from nursing home for increased temp and sats in 80's. In ED, found to be in rapid Afib, rate 130's, given dilt 10mg IV. CXR done-showed bilateral airspace opacities-likely aspiration PNA. Baseline dementia and combative upon arrival to ED. Rec'd Haldol 5mg and Ativan 0.5mg with little effect. Transferred to CCU as MICU border.\n\nNeuro/Social: Unable to assess orientation as pt is nonverbal. Opens eyes to stimulation and become agitated. Does not follow commands. Pulling at lines, pinching staff, and groaning. Soft wrist restarints applied to maintain integrity of lines. MAE. According to nursing home, pt was ambulating independently and feeding himself. Needs speech and swallow consult. No calls from family. DNR status in front of chart, signed by HCP, unknown relationship to pt. Gave Ativan 1mg IV with good effect and Zyprexa SL tab.\n\nCV: Afib, rate 130's as high as 160's upon arrival to unit. Rec'd total of Dilt 10mg IV x 3, with minimal effect. Rec'd lopressor 5mg IV with rate decrease to 80's. SBP 98-148/40-68. Hct 33.9. Lytes pending.\n\nRESP: Tachypneic up to 40's when agitated. 4L nc, sats 93-97. Productive cough, not expecotrating. Lungs clr c dim bases.\n\nGI/GU/Endo: Held all po meds as pt is a aspiration risk. Needs speeech and swallow. Mouth has missing teeth. BS present, no stool. Was guaiac positive in ED. Foley draining amber sedimented urine. Cx sent. IVF-D5 1/2NS @ 100cc/hr for 1500cc. Ist liter hanging. No endocrine issues.\n\nSkin/ID: Skin intact. Current temp 101.8 rectally. Gave tylenol 650mg PR @ 0600. Rec'd Levo/vanco/flagyl in ED. Started on levo and flagyl sched orders. WBC-13.1 (9.9).\n\nP: Cont to monitor HR and response to cardiac meds. Follow up c AM CXR and other labs. CXR this AM. Assess for agitation, treat prn. ?Speech/Swallow. Abx and fever. Emotionally support pt and family, keep updated on plan.\n" }, { "category": "Nursing/other", "chartdate": "2173-07-20 00:00:00.000", "description": "Report", "row_id": 1348739, "text": "CCU Nursing Progress Note 7am-7pm\nS:\n\nO: ID - Pt remains febrile, rectal temp 99.8, ax temp 99.6. Medicated w/ Tylenol 650mg per ngt x1. Flagyl and Levofloxacin dc'd. Zocyn and Vanc started. Blood and urine cultures pnd.\n\nCV - HR 80's afib w/ rare pvc's, singles and couplets. BP 84-112/40-50's. Diltiazem cont 30mg qid. Able to administer po at noon.\n\nResp - initially pt w/ bs at bases, otherwise clear. Throughout day, ls clear throughout. O2 sats 92-96% on 4ln/p. Pt has unproductive cough.\n\nGU - u/o minimal, 10-15cc/hr, dk amber cloudy w/ sediment. pt w/ maintenance IVF d5 1/2nss infusing at 100cc/hr. at 10am, Rec'd 1000cc NSS bolus w/ no increase in u/o. Also receiving volume w/ abx. Another 500cc bolus given at 3:45pm. u/o less concentrated through day, but volume continues to be low.\n\nGI- Tolerated sips of water without aspiration. Crushed Diltiazem and Digoxin in applesauce at noon. Tolerated without aspiration. Attempts x3 for NGT by this nurse, unsuccessful. MD's able to place NGT in r nares. Placement confirmed by CXR. Utilized for meds. Awaiting pump in order to initiate TF.\n\nNeuro - Pt opens eyes w/ stimuli and mumbles incomprehensible sounds. Moves all extremitites and will attempt to hit nursing staff. Wrist restraints inplace as well as 4 siderails up. Pt thrashes around in bed and has attempted to remove NGT and oxygen. Requiring close observation.\n\nSkin - small reddened area noted on coccyx 1cm x 1cm. Washed w/ soap and water and rubbed w/ aloevesta. Attempting to turn and position as he is cachectic, but will turn himself despite positioning. Elbows placed up on pillows and attempting to keep heels off bed. R wrist and hand eccyhmotic.\n\nSocial - No calls on pt's behalf today. Dr. to attempt to reach HCP.\n\nA: HR more controlled, Able to place ngt for med administration and nourishment, cont dry despite IVF bolus.\n\nP: cont monitor u/o and cont ivf bolus as necessary, initiate tf, maintain safety measures including bedrails and wrist restraints, mitts as necessary, close skin care monitoring attempting to keep off back/coccyx as tolerated, discussion w/ hcp per Dr. .\n" }, { "category": "ECG", "chartdate": "2173-07-19 00:00:00.000", "description": "Report", "row_id": 227081, "text": "Atrial fibrillation with a rapid ventricular response. Occasional ventricular\npremature beat. Voltage critria for left ventricular hypertrophy. Diffuse\nST-T wave changes, most likely related to rate and left ventricular\nhypertrophy. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2116-10-20 00:00:00.000", "description": "Report", "row_id": 1327416, "text": "MICU NPN 7P-7A\nNEURO: ALERT AND ORIENTED X3. PLEASANT. NEEDY AT TIMES. DENIES PAIN. MOVES INDEPENDANTLY IN BED. GIVEN ZYPREXA FOR SLEEP WITH GOOD EFFECT. H/O SEIZURE D/O, RECEIVED KEPPRA AND TRILEPTAL AT BEDTIME.\n\nCARDIAC: HR 116-137 ST WITH NO ECTOPY. EKG DONE THIS AM AS ROUTINE, TO BE SEEN BY MD. BP 71-115/39-61. HCT DRAWN PRIOR TO ARRIVAL WAS 26 UP FROM 15 AFTER 4UPC'S. RECEIVED ANOTHER UNIT PC'S WITH HCT ONLY TO 26.8. RECEIVED ANOTHER UNIT PC'S WITH MORNING HCT 28.5. AFTER RECEIVING 2U FFP IN ER EVENING INR 1.5. RECEIVED 10MG VIT K AFTER THAT WITH MORNING INR PENDING. NO SIGNS OF BLEEDING. PATIENT STILL HAD 12U PC'S ON HOLD IN BLOOD BANK. EF OF 35%.\n\nRESP: ON 2L N/C WITH RR 14-24 AND SATS 99-100%. AFTER RECEIVING 5TH UNIT PC'S AND 1L FLUID BOLUS FOR HYPOTENSION PATIENT C/O SOB WITH EXP WHEEZES AND BIBASILAR CRACKLES. PATIENT HAD CRACKLES ON ADMIT BUT WAS MORE PROMINENT NOW. MD AWARE AND UP TO EVAL. GIVEN 20MG LASIX AND ATROVENT NEB WITH GOOD STATED EFFECT. HAD ALWAYS MAINTAINED SATS SO O2 LEFT AT 2L. STILL WITH BIBASILAR CRACKLES BUT HE DID DROP HIS SBP TO 71 AFTER LASIX.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. HAD SMALL BROWN SMEAR LAST NIGHT. NO BLOOD. GIVEN A FLEETS ENEMA THIS MORNING FOR PREP OF COLONOSCOPY. ALSO TO HAVE EGD PERFORMED AS WELL. UOP 27-350CC/HR YELLOW AND CLEAR, S/P LASIX.\n\nFEN: RECEIVED 1L BOLUS FOR HYPOTENSION. +6L. LYTES PER CAREVUE. PATIENT REMAINS NPO FOR TESTS.\n\nID: TMAX 98.3 PO WITH WBC 6. NO CURRENT ID ISSUES. U/A PENDING.\n\nSKIN: W/D/I.\n\nACCESS: 3 LARGE BORE IV'S.\n\nSOCIAL/DISPO: DNR/DNI. NO HCP BUT CONTACT IS HIS BROTHER. BROTHER TOOK CANE HOME FROM ED. MONITOR Q4HR HCTS, TRANSFUSE FOR <30... MONITOR RESP STATUS AS PATIENT COULD EASILY FLASH...EGS AND COLONOSCOPY TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2116-10-20 00:00:00.000", "description": "Report", "row_id": 1327417, "text": "npn 7-7pm\n\nPt is a DNR/DNI. He has decompensated over the course of the day. At 1600 BP dropped to 69/37 with MAP in the 40's. Palliative care has been consulted. Spoke with Knob and decided to hold fluid boluses if possible. This RN attempted to call brother so that he can come and be with the patient. No answer, will call again later.\n\nneuro: At the beginning of the day pt was axox3, following commands. He is currently lethargic and difficult to arouse.\nDid wake patient at 1615 to assess that he was comfortable. Pt verbalized that he was.\n\nresp: Pt is on 2L nc and sats are 98%. LS with wheezes and he has crackles at the bases. HAve not given lasix because BP would not tolerate.\n\ncv: Afib 110-120. Early today had a rate of 140-150 for several hours.\nBP in the 60-70's treated with 500cc NS which was unsuccessful.\n\naccess: 3 piv.\n\ngi/gu: Belly is soft/distended with + BS. Patent foley with adequate u/o.\n\nSkin: Intact.\n\nDispo: Pt is a DNR/DNI. Will call brother to come in and have discussion regarding moving goal towards comfort. This topic was broached with brother this afternoon.\n\nPlan: Once brother arrives have discussion with team regarding CMO status.\n" }, { "category": "Nursing/other", "chartdate": "2116-10-21 00:00:00.000", "description": "Report", "row_id": 1327418, "text": "MICU NPN 7P-7A\nNEURO: AAOX3. NO PERIODS OF DECREASED MENTATION. DENIES PAIN. MOVING INDEPENDANTLY IN BED. NO SEIZURE ACTIVITY NOTED, ON KEPPRA AND TRILEPTAL. GIVEN ZYPREXA @HS WITH EXCELLENT RESULTS.\n\nCARDIAC: HR 65-92 SR WITH OCCASIONAL ECTOPY. BP 68-116/13-54. MD AWARE OF PERIODS OF SBP <80. NO TREATMENT AT THAT TIME, PATIENT WAS MENTATING WHEN AWOKEN AND HAD ADEQUATE UOP. HE WAS IN A SOUND SLEEP WITH LOWER BP'S. HCT STABLE @30-29.1, NO SIGNS OF BLEEDING. HAS NOT RECEIVED BLOOD PRODUCTS OVERNOC. NO C/O CHEST PAIN.\n\nRESP: REMAINS ON 2L N/C WITH RR 14-23 AND SATS 95-100%. DENIES SOB. LS WITH RIGHT BASE CRACKLES AND I/E WHEEZES.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. UOP 30-50CC/HR YELLOW AND CLEAR.\n\nFEN: +6L WITH CRACKLES NOTED. PEDAL EDEMA. LYTES PER CAREVUE. STARTED ON CLEAR LIQUIDS AND TOLERATING WELL.\n\nID: TMAX 98.9 WITH WBC OF 6. NO CURRENT ISSUES.\n\nSKIN: W/D/I.\n\nACCESS: PIV X3, RIGHT ART LINE.\n\nSOCIAL/DISPO: DNR/DNI. BROTHER CALLED LAST NOC AND WAS UPDATED. DID NOT COME IN. OTHER BROTHER FROM CALLED AND SPOKE WITH PATIENT. PATIENT KNOWS WITH HIS CA THAT PROGNOSIS IS POOR. HE WAS AMENABLE TO SCOPE IF NECESSARY AND IF SURGERY WAS AN OPTION HE WOULD TAKE IT. HE ALSO STATED THAT IF NOTHING CAN BE DONE ABOUT HIS CA THAT HE WAS \"A GONER\". EMOTIONAL SUPPRT GIVEN/QUESTIONS ANSWERED. WITH STABLE HCT POSSIBLE CALL OUT TO FLOOR, TRANSFER NOTE WRITTEN.\n" }, { "category": "Nursing/other", "chartdate": "2116-10-21 00:00:00.000", "description": "Report", "row_id": 1327419, "text": "npn 7-7pm\n\nMr had an uneventful day. His visited this afternoon and was updated by Dr , Oncology was consulted. There is a question whether or not to tap to determine if fluid in abdomen is cancerous.\n\nneuro: Pt is axox3, follows commands, MAE. No c/o pain or discomfort.\n\nresp: Sats 100% on 2L nc. LS with wheezing.\n\ncv:SR in the 60-70's, with PVC's. BP with MAP 55-60.\n\naccess: R radial aline, 3 piv.\n\ngi/gu: Belly is soft, distended with + BS. Adequate u/o.\nTaking clear liquids.\n\nDispo: DNR/DNI.\n\nPlan: Maintain comfort, called out to floor. Palliative care is consulting as is oncology.\n\n" }, { "category": "ECG", "chartdate": "2116-10-20 00:00:00.000", "description": "Report", "row_id": 125412, "text": "Regular wide complex tachycardia - probable supraventricular - mechanism\nuncertain - may be atrial flutter or atrial tachycardia with 2:1 response\nLow limb lead QRS voltages\nPoor R wave progression with late precordial QRS transition - consider\nanteroseptal myocardial infarct, age indeterminate\nRight ventricular conduction delay\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia\nConsider also RV overload or chronic pulmonary disease\nClinical correlation is suggested\nSince previous tracing of , tachycardia rate faster\n\n" }, { "category": "ECG", "chartdate": "2116-10-19 00:00:00.000", "description": "Report", "row_id": 125413, "text": "Regular wide complex tachycardia - probable supraventricular - mechanism\nuncertain may be atrial flutter or atrial tachycardia with 2:1 response\nLow limb lead QRS voltages\nPoor R wave progression with late precordial QRS transition - consider\nanteroseptal myocardial infarct, age indeterminate\nRight ventricular conduction delay\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia\nConsider also RV overload or chronic pulmonary disease\nClinical correlation is suggested\nSince previous tracing of , tachyarrhythmia and further ST-T wave\nchanges present\n\n" }, { "category": "ECG", "chartdate": "2116-10-28 00:00:00.000", "description": "Report", "row_id": 125544, "text": "Sinus rhythm. First degree A-V block. Right axis deviation. Anteroseptal\nmyocardial infarction of indeterminate age. Low QRS voltage in the limb leads.\nNon-specific lateral ST-T wave changes. Compared to the previous tracing\nof no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2116-10-22 00:00:00.000", "description": "Report", "row_id": 125545, "text": "Probable accelerated junctional rhythm. Long QTc interval. Right axis\ndeviation. Possible right ventricular conduction delay. Old anteroseptal\nmyocardial infarction. Lateral ST-T wave changes are non-specific. Low\nQRS voltage in the limb leads. Compared to the previous tracing of the\nrate is slower.\n\n" }, { "category": "ECG", "chartdate": "2116-10-20 00:00:00.000", "description": "Report", "row_id": 125546, "text": "Wide complex tachycardia - probably supraventricular - mechanism uncertain with\nvariable block\nLow limb lead QRS voltages\nPoor R wave progression with late precordial QRS transition - consider\nanteroseptal myocardial infarct, age indeterminate\nRight ventricular conduction delay\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia\nConsider also RV overload or chronic pulmonary disease\nClinical correlation is suggested\nSince previous tracing of , variable block now seen\n\n" }, { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 885450, "text": " 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pcxr r/o wide mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n pcxr r/o wide mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 71-year-old man with known aortic dissection.\n\n PORTABLE CHEST: There is moderate cardiomegaly. The aorta is calcified and\n slightly tortuous. The mediastinum does not appear widened. There is upper\n zone vascular redistribution and mildly increased interstitial markings. Note\n is made of a somewhat prominent and lucent left costophrenic angle. Lung\n markings are seen to this area and it is not felt to represent a pneumothorax.\n Median sternotomy wires are again noted. Osseous and soft tissue structures\n are stable.\n\n IMPRESSION: Mild CHF. Mediastinum does not appear widened.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 885465, "text": " 6:10 PM\n PORTABLE ABDOMEN Clip # \n Reason: GI bleed, eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with known annular lesion on CT 3 d ago, now with melena, hct\n 15, distended abdomen\n REASON FOR THIS EXAMINATION:\n GI bleed, eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 71-year-old man with known annular lesion now with melena and\n distended abdomen.\n\n PORTABLE ABDOMEN: There is a normal bowel gas pattern without evidence of\n obstruction. Air and stool is seen throughout the colon and rectum.\n Nasogastric tube tip is in the stomach. No intraperitoneal free air is\n identified. Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No evidence of obstruction or intraperitoneal free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-10-23 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 885982, "text": " 3:24 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: r/o DVT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cancer and right ankle swelling\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n NON-INVASIVE VENOUS STUDY OF THE RIGHT LOWER EXTREMITY.\n\n CLINICAL INDICATION: 71-year-old male with known cancer and right ankle\n swelling. Assess for DVT.\n\n The study is somewhat limited by the brawny edema throughout right and left\n lower extremities, which makes it difficult to achieve easy compressibility of\n any of the vessels. Normal wall-to-wall color flow and pulse flow waveforms\n were obtained from the groin to below the popliteal trifurcation on the right\n lower extremity. The veins were compressible with some increased degree of\n pressure due to the diffuse edema. Scans of the left common femoral vein also\n showed normal color flow and pulse waveforms.\n\n CONCLUSION: No evidence of DVT in the right lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2116-10-26 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 886249, "text": " 9:59 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: PLEASE MARK FOR PARACENTESIS BY NEEDLE LOCALIZATION FOR FLUID TO BE SENT FOR CYTOLOGY\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with likely metastatic colon cancer. No pathologic diagnosis.\n Had virtual cscope which showed transluminal mass at trasverse colon and\n omental studding.\n REASON FOR THIS EXAMINATION:\n Please perform paracentetids by needle localization for fluid to be sent for\n cytolgogy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ascites. Please mark the spot for paracentesis.\n\n COMPARISON: None.\n\n FINDINGS: Limited ultrasound of the four quadrants of the abdomen\n demonstrates a moderate amount of ascites. Right pleural effusion is present.\n A spot was marked in the left lateral abdomen for paracentesis by the primary\n team.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2190-12-02 00:00:00.000", "description": "Report", "row_id": 1632872, "text": "MICU NPN 1900-0700\n Pt is an 80yo male who was originally admitted to the on with presumed sepsis and partial SBO. He was fluid rescucitated and treated with abx. Sent to CC7 on . In the afternoon of the 21st, pt's NGT was noted to have coffee grounds and changed to dark red blood in the NGT. Pt's Hct fell from 23-> 18.5. Transfused with 2units of PRBC's. Transferred to MICU for further evaluation. Hct up to 23. GI in to evaluate. Unable to clear with lavage.\n\nSystems Review:\n\nGI: Unable to clear with lavage as stated. NGT remains on LCS, with small amts of maroon blood. +BS. Abdomen soft and distended. Very large abdomen on left side. Per team, felt to be fluid, not blood. GI spoke with pt's HCP, who prefers conservative measures. He refuses to put pt through EGD at this time. AM hct returned at 20.5. Ordered for 2 additional units of PRBC's. Currently NPO.\n\nCV: BP has been stable all night. HR has consistently been in the 110's, as shift progressed, HR into the 130's.\n\nResp: Arrived on RA with O2 sat of 93%. He was placed on 35% CN with o2 Sat up to 99%. LS CTA.\n\nNeuro: Per chart, pt has h/o dementia. Pt has been A&O times 3. Answering questions appropriately.\n\nSocial: Pt has 2 children, his daughter is MR, living in an assisted facility in FLA. A son, with whom he is estranged. His nephew is the HCP and wants to respect the pt's wishes of being a DNR/DNI. His wife also has dementia and is a resident at .\n\nGU: Neurogenic bladder: chronic foley. U/O adequate, at least 30cc/hr.\n\nIV: Unable to get any lag bore IV's in, currently has a TL.\n\nEndo: QID FS, receiving coverage per SS.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-12-02 00:00:00.000", "description": "Report", "row_id": 1632873, "text": "Nursing Progress Note.\n\nGI: EGD performed @ BS today revealing large ulcer @ GE jxn that was subsequently cautherized/injected c resolution of bleeding @ this site. However stomach mucosa was extremely friable tissue and if pt re-bleeds repeat EGD would be unhelpful and therefore contraindicated per GI note. Pt cont to receive blood products c HCT values slowly trending upward. Most recent HCT value of 25.7 (S/P six units PRBC's and two units FFP), pt now has the first of two units PRBC's now infusing @ BS. Pt med c a total of 3mg IVP Midazolam & 50mcg IVP Fentanyl for EGD c good tol/no adv rxn. Pt incontinent for two large loose/melanotic/hematochezia stools today, mushroom cath in place draining sm amounts of melanotic/hematochezia stool. One time 5mg SQ Vitamin K dose admin today. Abd remains large/obese/distended/soft c + BS appreciated today. No adv rxn to blood transfusions thus far today. Q12 hr PPI dosing in place. The pt is NPO. OGT d/c'ed during EGD, GI service currently feels the pt would not benefit from this device @ this time. Team discussing initiating TPN for nutritional support.\n\nMS: AAO times one, follows simple commands, and able to answer very simple yes/no questions (are you in pain) when given additional time to processing information. Pt freq re-oriented to person/time/place/ care rationale to assist nl cognition. Pt is cooperative. Soft wrist restraints d/c'ed earlier 2nd pt weakness/withdrawn state -- may need to be re-applied if pt cont to remove O2 face tent. Pt briefly c/o back pain today which seemed to improve c turn/re-positioning/back rub. Pt currently denies c/o pain.\n\nCV: Hemodynamically stable and afebrile. Sinus tachycardia all shift c HR in the 100-120's. Diff to palpate DP pulses. Venodyne boots in place for DVT prophylaxis. If pt does his BP, IV Neosynephrine would be the first line of pressors to be used per team. Pt currently receiving 3gm IV Calcium Gluconate for an AM Calcium value of 7.1.\n\nRESP: 35% FiO2 Cold steam face tent in place c nl sats in high 90's, RR in the teens/twenties and no evidence of SOB/dyspnea @ this time. Diminished BS throughout all lung fields, upper fields c some coarseness earlier in shift. No cough.\n\nGU: Pt c a few hours of low urinary output this afternoon (10-20ml/hr), urine lytes sent. Fortunately the pts hourly urinary output has increased in past two hours. The pt is currently net input 1.3 liters today and is nearly ten liters positive for LOS. + Anasarcoid. No diuretics ordered thus far today despite the pt receiving a total 7 units of blood prod (now on no. 8), team aware.\n\nDERM: L Heel dsg changed @ BS today. KinAir Med-surge air mattress in place.\n\nSOC: Son & dtr visited today and given pt information as requested by pt. The pt remains a DNR/DNI but will receive blood prod +/- IV Neo if his SBP falls.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-12-03 00:00:00.000", "description": "Report", "row_id": 1632874, "text": "MICU NURSING NOTES :\n\nNO SIGNIFICANT EVENTS TILL TIME NOTED.\n\nNEURO : LETHARGIC, DOZING INTERMITTENTLY, FOLLOWS COMMANDS, COOPERATIVE WITH CARE, DENIES PAIN, PARAPLEGIC- SENSATION LIMITED TO BLE. LIFTS & HOLDS BUE. SOFT WRIST RESTRAINTS DC'D.\n\nRESP : CONTINUED ON FACE TENT WITH 35 % O2, RR IN 20'S. LS CLEAR TO COARSE WITH DIMINISHED BASES. SPO2 IN 90'S.\n\nCVS : NSR/ ST ,NO ECTOPY SEEN. HR 90'S TO 100'S.120'S TO 130'S, MAP 60 TO 80'S. HCT UP TO 30.2 AT MIDNIGHT AFTER 2 UNITS OF PRBC. AM LABS PENDING. PULSES WEAK PALPABLE. SCD TO BLE FOR DVT PROPHYLAXIS, S/C HEPARIN DC'D ON . TPN TO BE RESTARTED, NUTRITION CONSULT ORDERED BY MD. PATENCY OF ONE OF THE LUMENS IN THE CENTRAL LINE CATHETER REESTABLISHED WITH 1 MG OF ATEPLASE.\n\nGI : ABDOMEN DISTENDED, BS PRESENT, REMAINS NPO. AS MD NO PLANS TO INSERT NGT AT PRESENT DUE TO RISK OF BLEEDING. MUSHROOM CATH DRAINING SMALL MELONOTIC STOOLS. ON IV PANTOPRAZOLE40 MG X 3 DAYS & THEN TO CHANGE TO PO.\n\nGU : FOLEY DRAINING ADEQUATE AMOUNTS OF YELLOW MILDLY SEDIMENTED URINE.\n\nID : AFEBRILE, CONTINUED ON FLAGYL, LEVOFLOXACIN.\n\nSKIN : ULCERS PRESENT ON BIL HEELS, DRESSING AS PER WOUND CARE RECOMMENDATIONS. ON KINIAIR MATTRESS.\n\nENDO : FINGERSTICKS Q 6 HRLY, RISS, REQUIRED COVERAGE.\n\nSOCIAL : NO CALLS OR VISITS FROM FAMILY.\n\nPLAN :\nCONTINUE MONITORING HCT/ LYTES.\nMONITOR I/O.\nTO START TPN AFTER NUTRITION CONSULT.\nEMOTIONAL SUPPORT TO PATIENT.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-11-30 00:00:00.000", "description": "Report", "row_id": 1632869, "text": "MICU NURSING PROGRESS NOTES :\n\nALLERGIC TO PROZAC.\n\nCODE STATUS : DNR/DNI\n\nEVENTS :FLUID BOLUSED FOR LOW URINE OUTPUT WITH MINIMAL EFFECT.\n\nNEURO : CALM, COOPERATIVE, O X 2 INITIALLY, REORIENTED TO PLACE, ALERT & ORIENTED X 3 IN AM, CONVERSES, FOLLOWS COMMANDS, NO MOVEMENT SEEN TO BLE (PARAPLEGIC), MOVES & HOLDS BUE WEAKLY.\n\nRESP : CONTINUES ON O2 2.5L/M VIA NC, SPO2 97 TO 99 %, LS CLEAR WITH DIMINISHED BASES. SHORT PERIODS OF SHALLOW RESP NOTED WHILE ASLEEP. HAS NONPRODUCTIVE COUGH.\n\nCVS : NSR, RARE PVC'S WITH MISSED BEATS OCCASIONALLY. SBP 100'S TO 130'S, MAP 60'S TO 80'S. CVP 7 TO 12, A-LINE TO LT RADIAL , MULTILUMEN PRESEP CATH TO LT SC, 1/2 NS @ 100 MLS/HR, AFEBRILE, CONTINUED ON FLAGYL, LEVAQUIN & VANCO. TROUGH SENT WITH PM DOSE- WITHIN THERAPEUTIC RANGE. HCT 23.5 FROM 23.8. WBC 7.6. INR 1.4\n\nGI : ABD DISTENDED & FIRM, BS HYPOACTIVE, BO- SMALL LOOSE YELLOW ; GUAIC POSIITVE, GASTROCCULT POSITIVE AS WELL, NGT TO LOW CONTINUOUS SUCTON DRAINED MODERATE AMOUNTS OVERNIGHT BILIOUS TO COFFEE GROUND IN COLOR. PM PO MEDS HELD.\n\nGU: FOLEY DRAINING YELLOW MILDLY CLOUDY 8 TO 50 MLS/HR, RESPONDED MINIMALLY TO 1 LIT FLUID BOLUS.\n\nSKIN : ULCERS TO BLE, DRESSING DONE AS PER ORDERS. SEE WOUND CARE ORDERS. BARI-AIR MATTRESS ORDERED, WILL BE IN BY 8 AM ON AS PER KCI. MULTIPODUS SOFT BOOTS ON. NEEDS FREQUENT TURNS.\n\nDVT PROPHYLAXIS : S/C HEPARIN & SCD TO BLE.\n\nENDO : ON RISS, NO COVERAGE REQUIRED TILL TIME NOTED.\n\nSOCIAL : NO VISITS OR CALLS FROM FAMILY TILL TIME NOTED. NEPHEW IS THE HCP.\n\nPLAN :\nMONITOR FOR BLEEDING.\nMONITOR HCT/ LYTES.\nMONITOR INTAKE /OUTPUT.\n? CALL OUT\n" }, { "category": "Nursing/other", "chartdate": "2190-11-30 00:00:00.000", "description": "Report", "row_id": 1632870, "text": "ADDENDUM :\n\n0500 HRS: U/O 10 MLS, STARTED ON NS AT 250 MLS/HR FOR 1000MLS OVER 4 HOURS. HELD THE 1/2 NS DRIP TILL THE ABOVE MENTIONED DRIP IS COMPLETED AS MD. CVP 5 TO 8.\n0630 HRS: STARTED POTASSIUM PHOSPHATE DRIP 30 MMOLS IN 500 MLS NS OVER 6 HOURS.\nPATIENT HAS VERY SHORT PERIODS OF APNOEA AT PRESENT WHILE ASLEEP, SPO2 FLUCTUATES LOW 90'S WITH GOOD PLETH, PICKS UP IMMEDIATELY TO 99 % WHEN HE TAKES A GOOD BREATH IN.\n" }, { "category": "Nursing/other", "chartdate": "2190-11-30 00:00:00.000", "description": "Report", "row_id": 1632871, "text": "neuro: alert and oriented x3. +movement BUE only. +perrla noted. denies pain or discomfort.\ncv: monitor shows nsr-st with occ pac noted. cvp 12-17. maps>65.\nresp: ls coarse bibasilar. no sob or resp distress noted. fio2 weaned to 2 lnp.\ngi: abd firm and distended. +hypo bs noted. inc soft brown stool x2(heme-). ngt->lws draining coffee ground secretions. remains npo, held po meds. to start on tpn this evening.\ngu: foley intact and patent draining yellow urine with sedimentation noted. urine cx sent.\nskin: bilat heel ulcers with mod amt brown drainage noted, wash with ns, aquacel ag, dsd and kling applied. bilat soft heel booties intact. duoderm to r calf area c/d/i. placed on kinair bed.\nendo: remains on fngersticks q6hr with riss.\ni-d: afebrile. vanco d/c'd. remains on flagyl and levofloxacin.\npsy-soc: no phone calls or visitors this shift. pt stating that he is \"afraid of dying\", emotional support provided and s/w consulted for coping. code status dnr/dni. c/o to medical floor awaiting bed.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-11-29 00:00:00.000", "description": "Report", "row_id": 1632866, "text": "TSICU Admit Note 1900-0700\n 80yo male admitted from with vomiting,distended abdomen.Febrile to 102.6, cx'd in ED, CT chest showed bilat basilar pneumonia, ? early bowel obstruction, 4x4cm infrarenal AAA.Hypotensive not responsive to fluid boluses, Levophed started.NG tube inserted, with improvement in BP after 1L bilious dge out.\n Pt resides at house with his wife.PMH includes,\n MS, paraplegia, neurogenic bladder,BLE ulcers\n Depression,anxiety\n Review of Systems\n Neuro-Pt is alert, generally oriented, vague and poor historian.NH reports some dementia. No movement of LE's(chronic), limited sensation of same.Weakly moves UE's.No c/o pain.\n CV-MP-SR, no ectopy.Weaned off , placed, MAP> 60 off pressors.CVP 8-12.6L IVF given, 1uPC's for Hct 27>21. 23.5 currently, IVF . to 100/hr.Pulses weakly+, pboots in place,SQ Heparin.CVL R SC, SVo2 monitor in place, recal, 95% at this time\n Resp- 2L NC, Sao2 100%, desats very briefly to 80S, back up to 100%.LS clear, very diminished at bases.Resp pattern -\n GI- abd softly distended, no BS 1700 cc bilious dge from NG since admit.Seen by surgery, pt agrees to if \"it will save my life\"-no plans for OR at this time.\n GU-Foley in place,u/o adequate>30/hr\n Skin-see carevue\n Labs- k=3.1,po4=1.9, Mg and Ca low also. Glucose per RISS,no coverage\n ID- WBC11.4>9.4, on triple abx day1.Afebrile overnight\n Social- Lives with wife at ,wife also has dementia. Pt has one son and daughter( and )-not involved in medical decision making. Proxy is nephew called by re:admit, no contaqct overnight\n Plan- monitor for worsening sepsis\n Pt is DNR/DNI\n Replete lytes\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-12-03 00:00:00.000", "description": "Report", "row_id": 1632875, "text": "Nursing Progress Note.\n\nCV: Hemodynamically stable and afebrile today c nl HR all shift. +2 Anasarca unchanged. 2gm IV Calcium Gluconate provided for AM serum Calcium value of 7.3. 30mmol Potassium Phosphate provided today for AM serum phosphate value of 2.0 & potassium value of 3.6. Repeat 16:00 HCT value of 30.3 noted. Repeat 16:00 INR value of 1.2 noted. Current type/screen in blood bank expires on @ 23:59. Venodyne boots in place. RISS in place.\n\nMS: Pt lethargic/sleeping most of shift, arouses to verbal stimuli and follows commands. Pt asking/receiving ice chips c/o dry mouth. Pt has denied c/o pain today. The pt is not restrained. Pt oriented to person only. Pt re-oriented freq today to person/place/time/care rationale to assist nl cognition.\n\nGI: No evidence of active GI bleeding thus far today. Pt cont to drain small amounts of melanotic stool via mushroom cath. Abd remains soft, distended c +BS appreciated. Speech/swallow performed @ BS, diet adv to soft consistancy and able to take pills in apple sauce. However, pt had diff taking pills in apple sauce and will therefore crush pills/add to apple sauce to facilitate PO intake of pills. TPN initiated today.\n\nRESP: 35% FiO2 Face tent in place c nl sats/RR/resp effort on bed rest today. +Exp wheeze appreciated today, RT providing Albuteral nebs PRN. No c/o SOB/dyspnea today.\n\nSOC: No calls or visitors thus far today. The pt remains a DNR/DNI.\n\nOTHER: Please see CareVue for additional pt care data/comments. Universal isolation precautions remain in place.\n" }, { "category": "Nursing/other", "chartdate": "2190-12-04 00:00:00.000", "description": "Report", "row_id": 1632876, "text": "MICU NURSING NOTES :\n\nNO SIGNIFICANT EVENTS OVERNIGHT.\n\nNEURO : ALERT, LETHARGIC AT TIMES, CALM & COOPERATIVE WITH CARE, FOLLOWS COMMANDS, DENIES PAIN. PARAPLEGIC, MOVES BUE.\n\nRESP : REMAINS ON 2 LITS O2 VIA NC, SPO2 HIGH 90'S, LS CLEAR WITH DIMINISHED BASES.\n\nCVS : NSR/ST, NO ECTOPY SEEN, SBP 120'S TO 130'S, MAPS 70'S TO 80'S. PM HCT 28.2, NO PLANS TO TRANSFUSE THEN, AM LABS PENDING. ON TPN VIA CENTRAL LINE.\n\nGI : ABD DISTENDED, PATIENT ABLE TO TOLERATE ORAL LIQUIDS AS ORDERED VERY WELL. BS PRESENT, MUSHROOM CATHETER DRAINING MELENOTIC STOOLS, GUAIC POSITIVE. TODAY IS THE 3RD DAY OF IV PANTOPRAZOLE, TO START ON PO DOSES FROM .\n\nGU : FOLEY DRAINING ADEQUATE AMOUNTS OF YELLOW MILDLY SEDIMENTED URINE.\n\nSKIN : SEE CAREVUE FOR DETAILS, ON KINIAIR MATTRESS. SCD'S & VENODYNE BOOTS ON BLE.\n\nENDO : FINGERSTICKS Q 4 HRLY, COVERED WITH RISS.\n\nID : AFEBRILE, CONTINUED ON FLAGYL & LEVOFLOXACIN.\n\nSOCIAL : NO CONTACT FROM FAMILY TILL TIME NOTED.\n\nPLAN :\nCONTINUE MONITORING HCT/LYTES.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-11-29 00:00:00.000", "description": "Report", "row_id": 1632867, "text": "Events: K/Mag/Calc repeleted, Kphos currently infusing at 90cc/hr.\n\n\nPt admitted last night with hx leukocytosis, distended abd/vomiting x1-2days. Abd CT consistent with partial bowel obstruction. Pt fluid rescusitated and initially on gtt for bp support. He has stablized overnight, is currently off pressors and denies nausea/vomiting or other distress. He wakes easily and is oriented x 2. He converses appropriately and communicates needs. Monitor shows SR/no ectopy, sbp 146/53. Lungs are clear bilaterally, 02 sat on 2.5l 98%. Urine out is 25-45cc/hr clear yellow. Abd is distended, semifirm with tympanic bs. NGT to lws draining brown bile in moderate quantity. Skin surfaces grossly intact, bilateral LE dressings clean and dry. Has required no insulin coverage this shift. HCP listed as pts nephew, no contact as of this time. Code status is DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2190-11-29 00:00:00.000", "description": "Report", "row_id": 1632868, "text": "MICU Nurse Progress Note 1100-1900\nPt transferred from TSICU where he was admitted from NH last night w/fever, abd distention, and vomiting last night. CT consistent w/ partial bowel . arrived w/ KPhos infusing at 90ml/hr, infusion finished rpt labs improved MD aware. pt was also on LR at 100ml/hr, changed to 1/2 N/s at 100ml/hr.\n\nNeuro: A/O x2 converses, follows commands. pt is paraplegic r/t M/S. PERRLS.\n\nPulm: LS clear bilat w/ dim bases. 02 sat 95-99% on 02 2.5L via n/c. pt noted to have short periods of apnea (20-25sec) when asleep.\n\nC/V: NSR w/ no ectopy HR 80's-90's, b/p 100's-130's/ 50's-60's. CVP 8-14\n\nAccess: L s/c presep cath, L A-line, and peripheral IV's x3.\n\nGI: NGT to low cont suction w/ sm-mod amt brown/bilious drainage. ABD firm distended w/ hypo b/s x 4 quads, pt rec. supp. w/ no results at this time.\n\nGU: foley cath patent draining clear dark yellow urine 25-40ml/hr.\n\nInteg: Bilat heel ulcers evaluated by wound care RN today, aquacel Ag dsg applied to bilat heels, adaptic to bilat feet.\n\nID: on flagyl/ vancomycin/ levaquin for ? asp PNA.vanco trough due before tonights dose.\n\nsocial: pt and wife live at , one son and one dghtr not involved in medical decisions. Nephew is HCP. contact from or HCP this shift.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-12-04 00:00:00.000", "description": "Report", "row_id": 1632877, "text": "Nursing Progress Note.\n\nCV/GU: Hemodynamically stable and afebrile. NSR c very rare PVC's. +2 Anasarca unchanged. Good hourly urinary output c 40-80ml of urine out per hour. The pt is currently net input about one liter today and is net input approx twelve liters for LOS. Urine spec sent for analysis to w/u hematuria. TPN remains in place for nutritional support.\n\nGI: Pt tol nectar thick PO intake s diff and will adv slowly to full solids as tol. Mushroom cath in place draining small amounts of grossly guaic + melanotic stool. Abd remains soft, distended/obese c +BS appreciated. 10:00 HCT value of 27.1 stable from previous HCT. Next HCT/lytes to be sent @ 16:00.\n\nRESP: 2LNCO2 in place c nl sats/RR/resp effort. +Exp wheezing this AM, responded well to PRN Albuteral neb.\n\nMS: Much more alert/interactive today. AAO times two. Follows commands. No c/o of pain/anxiety.\n\nDERM: Heel dsgs changed QD on night shift. KinAir MedSurge bed in place.\n\nSOC: No calls/visitors thus far today. The pt remains a DNR/DNI.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions remain in place.\n" }, { "category": "ECG", "chartdate": "2190-12-07 00:00:00.000", "description": "Report", "row_id": 297439, "text": "Probable sinus tachycardia with atrial premature beats, although consider\nalso possible multifocal atrial tachycardia. Borderline left axis deviation.\nLate precordial QRS transition. Modest non-specific ST-T wave changes.\nFindings are non-specific. Clinical correlation is suggested. Since previous\ntracing of rhythm is more irregular with atrial ectopy.\n\n" }, { "category": "ECG", "chartdate": "2190-12-06 00:00:00.000", "description": "Report", "row_id": 297440, "text": "Baseline artifact. Sinus tachycardia. Atrial premature beats. Low\nprecordial QRS voltage is non-specific. Since previous tracing of \nlow limb lead QRS voltage has improved and atrial ectopy is evident.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-12-01 00:00:00.000", "description": "Report", "row_id": 297441, "text": "Sinus tachycardia. Generalized low voltage is non-specific but clinical\ncorrelation is suggested. Since previous tracing earlier same date\nno significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-12-01 00:00:00.000", "description": "Report", "row_id": 297442, "text": "Sinus tachycardia. Borderline low QRS voltage. Left axis deviation.\nLeft anterior fascicular block. Diffuse non-diagnostic repolarization\nabnormalities. Compared to previous tracing of the heart rate is\nfaster. Otherwise, no major change.\n\n" }, { "category": "ECG", "chartdate": "2190-11-29 00:00:00.000", "description": "Report", "row_id": 297443, "text": "Sinus rhythm. Left axis deviation. There is a late transition consistent with\npossible prior anterior myocardial infarction. Low voltage in the precordial\nleads. Compared to the prior tracing ST-T wave changes have improved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-11-28 00:00:00.000", "description": "Report", "row_id": 297444, "text": "Artifact is present. Probable sinus tachycardia. Left axis deviation. There\nis a late transition with anterior and anterolateral ST-T wave changes\nconsistent with prior anterior myocardial infarction. Low voltage in the\nprecordial leads. Compared to the prior tracing evidence of prior anterior\nmyocardial infarction is new.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2199-02-01 00:00:00.000", "description": "Report", "row_id": 87230, "text": "PATIENT/TEST INFORMATION:\nIndication: 62y male POD#0 s/p total abd colectomy for c. diff colitis now with acute hypotension and acute anemia. Eval for cardiac tamponade.\nHeight: (in) 69\nWeight (lb): 205\nBSA (m2): 2.09 m2\nBP (mm Hg): 62/49\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 12:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPERICARDIUM: No echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position. Suboptimal image quality -\nbody habitus. Suboptimal image quality - ventilator. Suboptimal image quality\n- patient unable to cooperate. Resting tachycardia (HR>100bpm).\nDiificult TTE windows. Partial subcostal view. Converted to TEE after attempt\nat apical windows.\n\nConclusions:\nRight ventricular chamber size is normal with normal free wall contractility.\nThe mitral valve leaflets are not well seen. There are no echocardiographic\nsigns of tamponade. The left ventricular cavity is unusually small. Left\nventricular systolic function is hyperdynamic (EF>75%).\n\nIMPRESSION: Suboptimal image quality. Biventricular hyperdynamic state in the\npresence of underfilled left ventricle.\n\n\n" }, { "category": "Physician ", "chartdate": "2199-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 558634, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n subtotal colectomy\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Gabapentin 6.\n Heparin 7. 8. Insulin\n 9. Magnesium Sulfate 10. MetRONIDAZOLE (FLagyl) 11. Metoprolol Tartrate\n 12. Metoprolol Tartrate 13. Morphine Sulfate IR\n 14. Neutra-Phos 15. Potassium Chloride 16. Sodium Chloride 0.9% Flush\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate 19. Vancomycin Oral Liquid\n 24 Hour Events:\n --Cont\nd auto-diuresis\n --increased stool output\n --Remains with leukocytosis but no fever\n Post operative day:\n POD#9 - Subtotal colectomy\n POD#9 - exp lap and oversewing of messenteric vessel.\n POD#6 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:42 AM\n Vancomycin - 08:37 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:38 PM\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: 37.6\nC (99.6\n T current: 37.2\nC (98.9\n HR: 75 (68 - 108) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 23 (14 - 28) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 6 (-1 - 10) mmHg\n Total In:\n 2,094 mL\n 521 mL\n PO:\n Tube feeding:\n 1,698 mL\n 439 mL\n IV Fluid:\n 396 mL\n 81 mL\n Blood products:\n Total out:\n 6,270 mL\n 1,470 mL\n Urine:\n 3,300 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,176 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended, Tender: appropriate\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, decreased movement of lower ext\n per baseline.\n Labs / Radiology\n 399 K/uL\n 9.4 g/dL\n 195 mg/dL\n 0.3 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 8 mg/dL\n 106 mEq/L\n 140 mEq/L\n 27.0 %\n 19.5 K/uL\n [image002.jpg]\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n Plt\n 354\n 346\n 391\n 399\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n TCO2\n 32\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:2.0 g/dL, LDH:203 IU/L, Ca:8.1 mg/dL, Mg:2.4 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl, titrating up morphine for pain,\n restarted neurontin\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: pulm toilet, OOB\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n increased output from ostomy\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: lasix and albumin given yesterday, cont with goal 2 liters neg.\n Lasix prn if UO<100. Replete Phos today.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: IV flagyl/PO Vanco for CDiff, low grade temps and\n cont elevated wbc. Consider d/cing CVL if continues. Monitor wound\n for erythema.\n Lines / Tubes / Drains: foley, R IJ, aline.\n PIV\n Wounds: wet to dry. Monitor erythema inferior portion of wound.\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:10 PM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:26 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33\n" }, { "category": "Nursing", "chartdate": "2199-02-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558924, "text": "HPI: Pt is a 62M with multiple medical problems who was\n recently hospitalized (1/25-28/09) in the MICU for pneumonia, sepsis,\n and C-Diff colitis. He was discharged on a course of Vancomycin IV\n for MRSA pneumonia as well as PO vanco for the C Diff. He was noted to\n be febrile at his nursing home with mental status changes. He was\n also hypotensive. He was transferred to the\n ED where he initially had a blood pressure of 66/38. His IV\n access is extremely difficult and a R femoral CVL was placed.He was\n volume resuscitated with 7L IVF and pressors were started.\n Once he somewhat stabled a CT of the abdomen was obtained demonstrating\n worsened distal colonic wall thickening and edema. The ED then\n requested this surgical consult.\n No other HPI can be obtained given the patient's inability to answer\n questions. Family reports the patient normally is able to speak Spanish\n and understand English. The ED reports patient\n answers questions in English by blinking eyes. Reportedly patient had\n endorsed abdominal pain and was tender in the LLQ for the ED resident\n exams.\n s/p subtotal colectomy w ileostomy and takeback for bleeding left\n open.\n s/p expl lap, abd washout and closure on w/placement of Gtube.\n Extubated on \n PMH:\n -Multiple CVA's resulting in dysarthria, dysphagia (is able to\n eat purees and has a feeding tube) and inability to walk\n -h/o Afib (on Coumadin)\n -HTN\n -DM\n -h/o aspiration PNA\n -Depression\n -Neuropathic pain\n -hyperlipidemia\n -GERD\n -MRSA PNA \n -C Diff colitis \n -colonic distension -- previously evaluated by Dr. .\n Virtual colonoscopy negative for mass.\n -constipation\n PSH:\n -s/p lap chole at \n -s/p INH as child\n -Hip surgery\n -G/J tube\n Has been stable with sat 96-98% RA, strong cough and clearing\n secretions effectively. Declined speech and swallow and today.\n Continues on tube feeds at goal. Difficult to understand d/t speech but\n does communicate effectively by nodding and gestures. He continues to\n be high risk for aspiration. Case Management involved to see about\n short stay in a more aggressive rehab before going back to \n who has been in to evaluate him today.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 70 kg\n Daily weight:\n 77.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: CVA in ', aphasic, contractures, chronic\n constipation.\n Surgery / Procedure and date: Small bowel resec, colostomy, returned to\n or for blood in abdomen (4 Li\n ters), abd left open\n returnd t or for closure of abdomen\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:73\n Temperature:\n 96.6\n Arterial BP:\n S:89\n D:51\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,037 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:49 AM\n Potassium:\n 4.4 mEq/L\n 02:49 AM\n Chloride:\n 105 mEq/L\n 02:49 AM\n CO2:\n 29 mEq/L\n 02:49 AM\n BUN:\n 10 mg/dL\n 02:49 AM\n Creatinine:\n 0.3 mg/dL\n 02:49 AM\n Glucose:\n 142 mg/dL\n 02:49 AM\n Hematocrit:\n 26.1 %\n 02:49 AM\n Finger Stick Glucose:\n 184\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: SICU A\n Transferred to: 924\n Date & time of Transfer: @1600\n" }, { "category": "Nursing", "chartdate": "2199-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558611, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Breath sounds rhonchous, increase amt of secretitions. Appears to be\n having a difficult time handling the excessive amt of secretitons. Pt\n gagging.\n Action:\n Nasotracheal suctioned, turned q2hrs. chest pt. head of bed elevated.\n Response:\n Increase amt of secretitions.\n Plan:\n Suction prn monitor resp status. Chest xray today.\n Electrolyte & fluid disorder, other\n Assessment:\n Ostomy stoma pink and protruding. Large amt of liquid brown golden\n stool == 3450 cc in 12 hrs.\n Action:\n Electroytes drawn and repleted. I and O monitored very closely. Vs\n monitored. Cvp monitiored.\n Response:\n Increase amt of ostomy drainage.\n Plan:\n Monitor I and o closely.\n" }, { "category": "Nursing", "chartdate": "2199-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558426, "text": "Hypertension, benign\n Assessment:\n Bp to the 170-180\ns especially while moving in the bed.\n Action:\n Lopressor iv d/c\nd and lopressor 25mg via tube ordered and given.\n Fentanyl for pain control with morphine given prn.\n Response:\n Bp better controlled at 140-150\n Plan:\n Monitor bp control closely.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Breath sounds clear in the upper lobes with rhonchi in the lower lobes.\n Resp rate 15-30.\n Action:\n Nasotracheal suctioned for thick white yellow sputum. Chest pt q2hrs.\n turned in bed q2hrs. lasix 40mg iv p given. Cxr done.\n Response:\n O2sats 96-100%\n Plan:\n Monitor resp status closely.\n" }, { "category": "Physician ", "chartdate": "2199-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 558437, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n abdominal pain\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Duloxetine 5.\n Famotidine 6. Fentanyl Citrate\n 7. Furosemide 8. Gabapentin 9. Heparin 10. Insulin 11. Magnesium\n Sulfate 12. MetRONIDAZOLE (FLagyl)\n 13. Metoprolol Tartrate 14. Metoprolol Tartrate 15. Morphine Sulfate IR\n 16. Neutra-Phos 17. Potassium Chloride\n 18. Sodium Chloride 0.9% Flush 19. Sodium Chloride 0.9% Flush 20.\n Sodium Phosphate 21. Vancomycin Oral Liquid\n 24 Hour Events:\n to OR for colectomy\n take back to OR for bleed\n : FFP, cut back on IVF\n : takeback for closure, off pressors, improving\n : weaning off ps\n : desat early am. suctioned and put on cmv and sats improved.\n throughout day pt more alert/interactive. attempt at thoracentesis for\n left pleural effusion aborted given no sign fluid removal, UOP\n increased\n : refused speech/swallow, albumin and lasix given\n Post operative day:\n POD#8 - Subtotal colectomy\n POD#8 - exp lap and oversewing of messenteric vessel.\n POD#5 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:58 AM\n Metronidazole - 03:42 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 AM\n Metoprolol - 08:44 PM\n Furosemide (Lasix) - 11:04 PM\n Heparin Sodium (Prophylaxis) - 03:43 AM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 98 (85 - 116) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (13 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 5 (1 - 13) mmHg\n Total In:\n 3,128 mL\n 722 mL\n PO:\n Tube feeding:\n 1,686 mL\n 472 mL\n IV Fluid:\n 601 mL\n 250 mL\n Blood products:\n 200 mL\n Total out:\n 4,570 mL\n 1,900 mL\n Urine:\n 4,100 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,442 mL\n -1,178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///37/\n Physical Examination\n Gen: NAD, arousable\n HEENT: PERRL\n CV: RRR\n Pulm: CTA b/l\n Abd: soft, mildly distended, incision C/D/I, erythema improved\n Ext: + edema\n Neuro: Unchanged with contractures.\n Labs / Radiology\n 346 K/uL\n 9.4 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 5 mg/dL\n 101 mEq/L\n 143 mEq/L\n 27.6 %\n 20.2 K/uL\n [image002.jpg]\n 05:19 PM\n 02:20 AM\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n WBC\n 15.4\n 21.3\n 20.2\n Hct\n 26.2\n 30.1\n 27.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.3\n 0.3\n 0.4\n 0.4\n TCO2\n 32\n 33\n 32\n 35\n Glucose\n 84\n 93\n 112\n 186\n 166\n 154\n Other labs: PT / PTT / INR:15.1/37.0/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: wean off fentanyl, titrating up morphine for pain,\n restarted neurontin\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: pulmonary toilet, OOB\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: lasix and albumin given yesterday, cont with goal 2 liters neg.\n Aggressive phosphate repletion\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: IV flagyl/PO Vanco for CDiff, low grade temps and\n cont elevated wbc. Consider d/cing if continues to have increased\n WBC. Monitor wound for erythema.\n Lines / Tubes / Drains: Foley, NGT, , \n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Resp Failure;\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:06 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 12 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558785, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain intermittently throughout shift.\n Action:\n Pt with fentanyl patch at 25mcg intact, pt given 15 mg MSIR X 2 for\n breakthrough pain\n Response:\n Pt able to sleep in long naps after additional pain med\n Plan:\n Monitor pain level, medicate as needed for comfort\n" }, { "category": "Nutrition", "chartdate": "2199-02-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 558896, "text": "Current Wt: 73kg\n Adm Wt: 70kg\n Pertinent medications: RISS, Abx, Pepcid, Neutraphos, others noted\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 02:49 AM\n Glucose Finger Stick\n 184\n 10:00 AM\n BUN\n 10 mg/dL\n 02:49 AM\n Creatinine\n 0.3 mg/dL\n 02:49 AM\n Sodium\n 138 mEq/L\n 02:49 AM\n Potassium\n 4.4 mEq/L\n 02:49 AM\n Chloride\n 105 mEq/L\n 02:49 AM\n TCO2\n 29 mEq/L\n 02:49 AM\n PO2 (arterial)\n 196 mm Hg\n 12:09 PM\n PCO2 (arterial)\n 55 mm Hg\n 12:09 PM\n pH (arterial)\n 7.39 units\n 12:09 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 12:09 PM\n Albumin\n 3.4 g/dL\n 02:49 AM\n Calcium non-ionized\n 8.0 mg/dL\n 02:49 AM\n Phosphorus\n 2.1 mg/dL\n 02:49 AM\n Ionized Calcium\n 1.10 mmol/L\n 02:35 AM\n Magnesium\n 2.0 mg/dL\n 02:49 AM\n ALT\n 82 IU/L\n 03:10 AM\n Alkaline Phosphate\n 43 IU/L\n 03:10 AM\n AST\n 31 IU/L\n 03:10 AM\n Amylase\n 74 IU/L\n 03:10 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:10 AM\n WBC\n 16.2 K/uL\n 02:49 AM\n Hgb\n 8.9 g/dL\n 02:49 AM\n Hematocrit\n 26.1 %\n 02:49 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 70cc/hr (1680kcals, 104g protein)\n GI: soft, + BS\n Assessment of Nutritional Status\n 62 y.o. M s/p colectomy due to proctocolitis c diff with take-back\n to OR for bleeding. Pt is now tolerating TF at goal, which meets 100%\n of est needs. Pt is now off O2. Pt has been seen by SLP x2 and has\n communicated that he does not feel ready for po\ns yet, so pt remains\n NPO. Pt\ns Phos remains low even with daily neutral-phos; rec starting\n IV Phos repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with TF at goal.\n 2) Rec IV phos repletions until Phos WNL.\n 3) Monitor BG, lytes.\n 4) Please page with ?\ns #\n 5) Electronically signed by , RD, LDN \n 13:00\n 6)\n 7)\n" }, { "category": "Physician ", "chartdate": "2199-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 558603, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n subtotal colectomy\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Gabapentin 6.\n Heparin 7. 8. Insulin\n 9. Magnesium Sulfate 10. MetRONIDAZOLE (FLagyl) 11. Metoprolol Tartrate\n 12. Metoprolol Tartrate 13. Morphine Sulfate IR\n 14. Neutra-Phos 15. Potassium Chloride 16. Sodium Chloride 0.9% Flush\n 17. Sodium Chloride 0.9% Flush\n 18. Sodium Phosphate 19. Vancomycin Oral Liquid\n 24 Hour Events:\n Post operative day:\n POD#9 - Subtotal colectomy\n POD#9 - exp lap and oversewing of messenteric vessel.\n POD#6 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:42 AM\n Vancomycin - 08:37 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:38 PM\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: 37.6\nC (99.6\n T current: 37.2\nC (98.9\n HR: 75 (68 - 108) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 23 (14 - 28) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 6 (-1 - 10) mmHg\n Total In:\n 2,094 mL\n 521 mL\n PO:\n Tube feeding:\n 1,698 mL\n 439 mL\n IV Fluid:\n 396 mL\n 81 mL\n Blood products:\n Total out:\n 6,270 mL\n 1,470 mL\n Urine:\n 3,300 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,176 mL\n -949 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended, Tender:\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 399 K/uL\n 9.4 g/dL\n 195 mg/dL\n 0.3 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 8 mg/dL\n 106 mEq/L\n 140 mEq/L\n 27.0 %\n 19.5 K/uL\n [image002.jpg]\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n Plt\n 354\n 346\n 391\n 399\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n TCO2\n 32\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:2.0 g/dL, LDH:203 IU/L, Ca:8.1 mg/dL, Mg:2.4 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl, titrating up morphine for pain,\n restarted neurontin\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: pulm toilet\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n increased output from ostomy\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: lasix and albumin given yesterday, cont with goal 2 liters neg.\n Lasix prn if UO<100\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: IV flagyl/PO Vanco for CDiff, low grade temps and\n cont elevated wbc. Consider d/cing CVL if continues. Monitor wound\n for erythema.\n Lines / Tubes / Drains: foley, R IJ, aline.\n PIV\n Wounds: wet to dry. Monitor erythema inferior portion of wound.\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:10 PM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:26 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2199-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558713, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558715, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n At start of shift, LS with rhonchi throughout and O2 sats > 94% on 5\n liters.\n Action:\n Chest PT, OOB to chair for 2 hours, encouraging pt to expectorate\n secretions, weaned O2.\n Response:\n Currently pt with O2 sats wnl ra and LSCTA.\n Plan:\n Continue chest PT, aggressive pulmonary hygiene, monitor O2 sats\n closely.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal/incisional pain.\n Action:\n Fentanyl patch applied, IR morphine prn.\n Response:\n Pt observed resting comfortable after pain med admin.\n Plan:\n Continue to monitor pain closely and medicate prn.\n" }, { "category": "General", "chartdate": "2199-02-11 00:00:00.000", "description": "Generic Note", "row_id": 558885, "text": "TITLE: Attempted Bedside Swallow Evaluation\n I spent 20 minutes with the pt today in attempts to complete the\n swallow evaluation. Pt is extremely communicative via yes/no head nods\n and gestures and expressed his need to be repositioned, to change the\n tv channel and that he was not yet ready to attempt anything PO. Please\n see Web OMR or paper chart for additional details.\n , MS, CCC-SLP\n Pager#\n 12:22\n" }, { "category": "Respiratory ", "chartdate": "2199-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557678, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\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: Clear / Thin\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:\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 Patient switched to PSV doing OK on current settings with good ABG may\n be extubated in AM\n" }, { "category": "Nutrition", "chartdate": "2199-02-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 557809, "text": "Adm Wt: 70kg\n Current Wt: 85.7kg\n Pertinent medications: Fentanyl, Propofol, RISS, Famotidine, Abx,\n albumin, others noted\n Labs:\n Value\n Date\n Glucose\n 74 mg/dL\n 08:26 AM\n Glucose Finger Stick\n 94\n 10:00 AM\n BUN\n 8 mg/dL\n 03:10 AM\n Creatinine\n 0.5 mg/dL\n 03:10 AM\n Sodium\n 144 mEq/L\n 03:10 AM\n Potassium\n 3.5 mEq/L\n 03:10 AM\n Chloride\n 111 mEq/L\n 03:10 AM\n TCO2\n 28 mEq/L\n 03:10 AM\n PO2 (arterial)\n 89. mm Hg\n 11:08 AM\n PCO2 (arterial)\n 46 mm Hg\n 11:08 AM\n pH (arterial)\n 7.40 units\n 11:08 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 11:08 AM\n Albumin\n 2.0 g/dL\n 03:06 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:10 AM\n Phosphorus\n 2.4 mg/dL\n 03:10 AM\n Ionized Calcium\n 1.17 mmol/L\n 08:26 AM\n Magnesium\n 2.0 mg/dL\n 03:10 AM\n ALT\n 82 IU/L\n 03:10 AM\n Alkaline Phosphate\n 43 IU/L\n 03:10 AM\n AST\n 31 IU/L\n 03:10 AM\n Amylase\n 74 IU/L\n 03:10 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:10 AM\n WBC\n 12.9 K/uL\n 03:10 AM\n Hgb\n 8.3 g/dL\n 03:10 AM\n Hematocrit\n 24.2 %\n 03:10 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 70cc/hr (1680kcal, 104g protein)\n GI: slightly distended\n Assessment of Nutritional Status\n 62 y.o. M adm with severe c diff colitis, now s/p colectomy with end\n ileostomy, with take-back to OR for bleeding , and then for abd\n closure . Pt was started on trophic TF via G-J-tube last night,\n and pt is tolerating well so far. Plan to continue to advance TF rate\n as tolerated. Current goal will provide roughly meet pt\ns estimated\n needs. Will adjust TF goal as needed based on pt\ns clinical progress.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec cont to advance to TF goal of Replete with Fiber @\n 70cc/hr. Adv 10cc q6-8hrs to goal.\n 2) Rec 50cc H20 q3hrs for hydration.\n 3) No residual checks with J-tube feeds, monitor tolerance with\n abd exam.\n Following\n please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2199-02-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558917, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. with temp 103 oral, lethargic and hypotensive with sbp in\n 70s. Pt had recently completed course of oral vanco for c-diff.\n Started on fluids, levo, dopamine, and vasopressin in ED. s/p subtotal\n colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n" }, { "category": "Respiratory ", "chartdate": "2199-02-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557916, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\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: No\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: Yellow / 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 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 on CPAP/PSV 5/5 and 40%. PSV increased to 10 d/t\n elevating pc02. will plan to wean support as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557859, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\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: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\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: Clear / Thin\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:\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: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Plan to extubate in\n AM\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient weaned on PSV this evening. Was to sedated to maintain adequate\n breathing this morning .BS diminished ,suctioned for minimal amount of\n thin clear secretion , ABG acceptable. Plan to extubate in AM\n" }, { "category": "Nursing", "chartdate": "2199-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557755, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated\n On CPAP 12/5 40%\n RR 7-10\n Stable tidal/minute volumes\n ABG this am stable\n Pressure support decreased to 10\n volume stable\n At 0500 sats down to high 80\ns, placed on 100% and sx\n abg post sxn\n wnl\n ~10 min later sats down to high 70\n Action:\n Placed on 100%\n SICU resident notified and CXR ordered\n Resp tx to bedside and placed on AC 500 x 12 Peep 8\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557756, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated\n On CPAP 12/5 40%\n RR 7-10\n Stable tidal/minute volumes\n ABG this am stable\n Pressure support decreased to 10\n volume stable\n At 0500 sats down to high 80\ns, placed on 100% and sx\n abg post sxn\n wnl\n ~10 min later sats down to high 70\n Action:\n Placed on 100%\n SICU resident notified and CXR ordered\n Resp tx to bedside and placed on AC 500 x 12 Peep 8\n Response:\n Sats 100%\n ABG shows adequate oxygenation and ventilation\n Plan:\n Wean as tolerated. CXR showed +right effusion and congestion. Team to\n discuss Lasix.\n" }, { "category": "Physician ", "chartdate": "2199-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 557766, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n respiratory distress, colectomy\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 5. Dextrose 50% 6. Dextrose 50% 7. Famotidine 8. Fentanyl Citrate 9.\n Heparin 10. Heparin Flush (10 units/ml)\n 11. Insulin 12. Magnesium Sulfate 13. MetRONIDAZOLE (FLagyl) 14.\n Potassium Chloride 15. Propofol\n 16. Sodium Chloride 0.9% Flush 17. Sodium Chloride 0.9% Flush 18.\n Vancomycin Oral Liquid\n 24 Hour Events:\n desat overnight. suctioned and put on cmv. sats improved.\n Post operative day:\n POD#5 - Subtotal colectomy\n POD#5 - exp lap and oversewing of messenteric vessel.\n POD#2 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Metronidazole - 04:00 AM\n Vancomycin - 08:01 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Fentanyl - 09:30 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Dextrose 50% - 04:30 AM\n Famotidine (Pepcid) - 08:01 AM\n Other medications:\n Flowsheet Data as of 08:24 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: 36.9\nC (98.4\n HR: 89 (69 - 100) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 18 (6 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 9 (2 - 15) mmHg\n Total In:\n 2,362 mL\n 1,152 mL\n PO:\n Tube feeding:\n 60 mL\n 83 mL\n IV Fluid:\n 1,752 mL\n 645 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 2,370 mL\n 1,300 mL\n Urine:\n 1,870 mL\n 1,300 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -8 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (400 - 500) mL\n Vt (Spontaneous): 667 (536 - 788) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/42/154/28/3\n Ve: 9 L/min\n PaO2 / FiO2: 385\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 148 K/uL\n 8.3 g/dL\n 66 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 111 mEq/L\n 144 mEq/L\n 24.2 %\n 12.9 K/uL\n [image002.jpg]\n 07:39 AM\n 12:53 PM\n 01:03 PM\n 07:18 PM\n 09:00 PM\n 10:00 PM\n 03:10 AM\n 03:21 AM\n 04:55 AM\n 06:26 AM\n WBC\n 12.9\n Hct\n 24.2\n Plt\n 148\n Creatinine\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 30\n 28\n 28\n Glucose\n 70\n 65\n 124\n 109\n 66\n Other labs: PT / PTT / INR:14.6/49.1/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:7.5 mg/dL, Mg:2.0 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt, fentanyl gtt\n Cardiovascular: HD stable, off pressors\n Pulmonary: wean vent as tolerated\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft,\n bladder pressures normal\n Nutrition: Trophic feeds today\n Renal: takes lasix at home. Will KVO as tolerated. UOP adequate.\n Albumin 25 gm x3 on .\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl. PO Vanco started .\n zosyn d/ced .\n Lines / Tubes / Drains: foley, R IJ, aline, JP.\n Wounds: wet to dry\n Imaging:\n Fluids: Albumin\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2199-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 558105, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n lethargy\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 5. Famotidine 6. Fentanyl Citrate 7. Furosemide 8. HYDROmorphone\n (Dilaudid) 9. Heparin 10. Heparin Flush (10 units/ml)\n 11. Insulin 12. Magnesium Sulfate 13. MetRONIDAZOLE (FLagyl) 14.\n Potassium Chloride 15. Propofol\n 16. Sodium Chloride 0.9% Flush 17. Sodium Chloride 0.9% Flush 18.\n Vancomycin Oral Liquid\n 24 Hour Events:\n to OR for colectomy\n take back to OR for bleed\n : FFP, cut back on IVF\n : takeback for closure, off pressors, improving\n : weaning off ps\n : desat early am. suctioned and put on cmv and sats improved.\n throughout day pt more alert/interactive. attempt at thoracentesis for\n left pleural effusion aborted given no sign fluid removal, UOP\n increased\n Post operative day:\n POD#6 - Subtotal colectomy\n POD#6 - exp lap and oversewing of messenteric vessel.\n POD#3 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Vancomycin - 02:00 AM\n Metronidazole - 05:21 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:39 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: 36.6\nC (97.9\n HR: 88 (74 - 111) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 10 (7 - 54) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.6 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 7 (2 - 11) mmHg\n Total In:\n 2,731 mL\n 1,031 mL\n PO:\n Tube feeding:\n 448 mL\n 384 mL\n IV Fluid:\n 1,458 mL\n 547 mL\n Blood products:\n 300 mL\n 100 mL\n Total out:\n 5,180 mL\n 2,370 mL\n Urine:\n 5,180 mL\n 2,270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,449 mL\n -1,339 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 676 (462 - 676) mL\n PS : 5 cmH2O\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.38/52/123/29/4\n Ve: 4.8 L/min\n PaO2 / FiO2: 308\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, Tender: over incision appropriately\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 219 K/uL\n 9.2 g/dL\n 93 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 3 mg/dL\n 110 mEq/L\n 146 mEq/L\n 26.2 %\n 15.4 K/uL\n [image002.jpg]\n 10:00 PM\n 03:10 AM\n 03:21 AM\n 04:55 AM\n 06:26 AM\n 08:26 AM\n 11:08 AM\n 05:19 PM\n 02:20 AM\n 02:35 AM\n WBC\n 12.9\n 15.4\n Hct\n 24.2\n 26.2\n Plt\n 148\n 219\n Creatinine\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 28\n 28\n 30\n 30\n 32\n Glucose\n 109\n 66\n 74\n 84\n 93\n Other labs: PT / PTT / INR:15.3/48.3/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:7.7 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt weaned, fentanyl gtt\n Cardiovascular: HD stable\n Pulmonary: wean vent as tolerated, spont breathing trial and possible\n extubation today\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n Nutrition: tube feeds advanced yesterday\n Renal: UOP increased. Albumin 25 gm x3 on . diuresed 2.5L yesterday\n without lasix gtt\n will cont to follow UOP and give Lasix PRN for goal\n 1-2 liters negative today.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: low grade temp, cdiff, Started on flagyl. PO Vanco\n started . zosyn d/ced .\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), low grade\n temp, cdiff, Started on flagyl. PO Vanco started . zosyn d/ced\n .\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids: Albumin TID today\n Consults: General surgery\n Billing Diagnosis: Post-op complication, Peritonitis; Resp failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-02-08 00:00:00.000", "description": "Intensivist Note", "row_id": 558212, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 09:33 AM\n INVASIVE VENTILATION - STOP 09:34 AM\n morphine started but pain still remains an issue, extubated, self\n diuresing 2.6L yesterday\n Post operative day:\n POD#7 - Subtotal colectomy\n POD#7 - exp lap and oversewing of messenteric vessel.\n POD#4 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Vancomycin - 02:19 AM\n Metronidazole - 04:11 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:45 PM\n Hydralazine - 09:15 PM\n Heparin Sodium (Prophylaxis) - 04:11 AM\n Metoprolol - 04:11 AM\n Famotidine (Pepcid) - 07:57 AM\n Other medications:\n Flowsheet Data as of 09:05 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: 36.7\nC (98\n HR: 100 (80 - 111) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 15 (9 - 27) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 13 (0 - 13) mmHg\n Total In:\n 2,953 mL\n 1,313 mL\n PO:\n Tube feeding:\n 1,441 mL\n 630 mL\n IV Fluid:\n 1,252 mL\n 263 mL\n Blood products:\n 100 mL\n Total out:\n 5,635 mL\n 1,500 mL\n Urine:\n 5,385 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,682 mL\n -187 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SPO2: 96%\n ABG: 7.39/55/196/31/7\n PaO2 / FiO2: 490\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), shovel mask in place\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: erythema at base of abdominal wound\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 354 K/uL\n 10.2 g/dL\n 186 mg/dL\n 0.3 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 4 mg/dL\n 102 mEq/L\n 141 mEq/L\n 30.1 %\n 21.3 K/uL\n [image002.jpg]\n 08:26 AM\n 11:08 AM\n 05:19 PM\n 02:20 AM\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n WBC\n 15.4\n 21.3\n Hct\n 26.2\n 30.1\n Plt\n 219\n 354\n Creatinine\n 0.4\n 0.4\n 0.3\n 0.3\n TCO2\n 30\n 30\n 32\n 33\n 32\n 35\n Glucose\n 74\n 84\n 93\n 112\n 186\n Other labs: PT / PTT / INR:14.7/36.5/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:1.2 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: fentanyl gtt. Started morphine 15Q4h, restart home\n neurontin\n Cardiovascular: lop 15Q4h; hydral prn\n Pulmonary: Extubated; pulmonary toilet\n GI: s/p abdominal closure, follow erythema around wound; abdomen soft\n Nutrition: tube feeds advanced to goal\n Renal: KVO; diuresed without lasix, 2.6 L neg yesterday; Na 141 so will\n decrease free water replacement; continue albumin one more day \n today\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: leukocytosis, low grade temp, cdiff, IV flagyl. PO\n Vanco started . zosyn d/ced .\n Lines/Tubes/Drains: foley, R IJ, aline\n Wounds: open to air with mild erythema\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Surgery\n Disposition: SICU\n Consults: general surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:41 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558283, "text": "Hypertension, benign\n Assessment:\n Pt hypertensive to 170\n Action:\n Lopressor dose increased to 7.5mg Q4hrs, Morphine increased to Q2hrs\n PRN.\n Response:\n Able to obtain SBP in 150\ns for short time.\n Plan:\n ? change to PO Lopressor for increased duration of effect. Diurese to\n remove fluid overload.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with long standing dysphasia following CVA in .\n Action:\n Seen by speech and swallow to evaluate.\n Response:\n Pt refused to participate in assessment, understands need for test but\n did not feel up to it.\n Plan:\n Continue with Tube Feeds and Meds via PEJ, reassess prior to discharge.\n" }, { "category": "Nursing", "chartdate": "2199-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558362, "text": "Hypertension, benign\n Assessment:\n Bp to the 170-180\ns especially while moving in the bed.\n Action:\n Lopressor iv d/c\nd and lopressor 25mg via tube ordered and given.\n Fentanyl for pain control with morphine given prn.\n Response:\n Bp better controlled at 140-150\n Plan:\n Monitor bp control closely.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Turn q2hrs.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557059, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure monday\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 5. ABG due at 1700\n Response:\n No change in pt status. Post ABG\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr.\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 558803, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Fentanyl Patch 6.\n Gabapentin 7. Heparin\n 8. 9. Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl) 12.\n Metoprolol Tartrate 13. Metoprolol Tartrate\n 14. Morphine Sulfate IR 15. Neutra-Phos 16. Potassium Chloride 17.\n Sodium Chloride 0.9% Flush 18. Sodium Chloride 0.9% Flush\n 19. Sodium Phosphate 20. Vancomycin Oral Liquid\n 24 Hour Events:\n no acute events, pain management improved\n Post operative day:\n POD#10 - Subtotal colectomy\n POD#10 - exp lap and oversewing of messenteric vessel.\n POD#7 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:19 AM\n Metronidazole - 03:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:18 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: 36.8\nC (98.3\n HR: 73 (71 - 90) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (12 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 4 (1 - 11) mmHg\n Total In:\n 2,503 mL\n 657 mL\n PO:\n Tube feeding:\n 1,783 mL\n 436 mL\n IV Fluid:\n 470 mL\n 131 mL\n Blood products:\n Total out:\n 2,450 mL\n 680 mL\n Urine:\n 1,250 mL\n 580 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 53 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminished\n bilateral bases)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Follows simple commands, moves b/l upper extremities and is\n able to hold, occasionally spontaneously moves lower extremities but\n unable to hold, garbled speech\n Labs / Radiology\n 391 K/uL\n 8.9 g/dL\n 142 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.1 %\n 16.2 K/uL\n [image002.jpg]\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n 02:49 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n 16.2\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n 26.1\n Plt\n 354\n 346\n 391\n 399\n 391\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n 142\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:3.4 g/dL, LDH:203 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl gtt, started fentanyl patch 25mcg/hr,\n IR morphine prn pain, neurontin, pain overall improved\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: requires suctioning, but maintains airway and SpO2,\n pulmonary toilet, OOB to chair\n GI: s/p abdominal closure, abdomen soft, stool output no longer with\n large volumes\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: continues with good UOP. off albumin now.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: IV flagyl/PO Vanco for CDiff. afebrile,\n leukocytosis.\n Lines/Tubes/Drains: foley, R IJ, aline, PIV.\n Wounds: erythema inferior portion of wound.\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Surgery\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:15 AM\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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2199-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557909, "text": "Electrolyte & fluid disorder, other\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": "2199-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556923, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admission for pneumosepsis due to aspiration treated\n with IV vanco. Today, found with temp 103 oral, lethargic and\n hypotensive with sbp in 70s. Pt had recently completed course of oral\n vanco for c-diff. Started on fluids, levo, dopamine, and vasopressin\n in ED.\n Chief complaint:\n Abdominal pain\n PMHx:\n Hypertension, CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic ; Type II Diabetes mellitus, Peripheral neuropathy,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Patient returned from or at @10am having had right colectomy for cdiff\n colitis. On arrival to unit patient intubated, on neo 1.5mcgs, patient\n had EBL 800, was given 4500 crystalloid, 3 FFP. 500 albumin in Or.\n Patient became hypovolemic ,tachycardic hypotensive. Patient given\n 5litres of NS, 3 liters of Lr. 500mls x2 of hespan. 2 units of blood,\n patient returned to OR and Had ex lap oversewing messenteric vessel,\n wound remains open, with jp drain to suction.\n In OR patient had 4litre EBL, given 8 units PRBC, 2 FFP, 2 liters LR.\n .H/O acidosis, Metabolic\n Assessment:\n Repeat abg preformed Ph 7.01 -6.81, Patient became very hypotensive\n despite having iv neo 3mcgs. Levo .mcgs and multi fluid bolus.. \n distended. No urine output. Temp 92, hypovolemic shock\n Action:\n IV bicarb 1 amp, iv calcium chloride 2 amps given. Iv pressers\n increased to max, iv vasopressin started at 1.2units and increased to\n 2.4units. 2 units PRBCs transfused. Rapid transfusion of fluids and\n blood products started, patient had vigello connected. Iv vasopressin\n 40units bolus given. Patient brought back to Or and had exp lap\n oversewing of mesenteric vessel, abdominal wound open with jp to\n suction on return from or.\n Response:\n on return from OR Ph 7.24-7.40, Patient in sinus rhythm BP Map >60 on\n Lev of 0.1mcg\n Plan:\n To continue to monitor and treat accordingly, wean off levo as\n tolerated. Patient to return to OR on Monday for closure of wound.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient intubated lungs clear but diminished. O2 sats 100% on 70% fio2.\n Abg preformed Ph 7.32, Pco2 39, and Po2 227.\n Action:\n Cxr obtain to check tube placement. Ett repositioned and advanced\n 1-2cm. Fio2 reduced to 40%. Pulmonary toileting preformed.\n Response:\n Maintaining good gas exchange, lungs clear but diminished.\n Plan:\n To continue to monitor Abg\ns wean off vent when patient stable.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient had no urine output, Hypotensive. Tachycardic.\n Action:\n Patient given rapid infusion of blood products and fluids. Iv pressers\n in progress to maintain kidney perfusion. Patient returned to Or and\n had oversewing of Mesenteric vessel.\n Response:\n On return from OR (second surgery) patient is passing clear yellow\n urine adequate amounts see icu flow sheet. Cvp +11 +13\n Plan:\n To continue to monitor urine output, cvp . Inform MD\ns if output\n drops.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Patient became very hypotensive despite being on iv pressers and having\n multi fluid boluses and blood products, Hct had dropped to 8, Ph 6.8\n became very distended, no urine output. Tachycardic.\n Action:\n Patient had rapid transfuser used to transfuse fluids and blood\n products. Patient returned to OR and had exp lap and oversewing of\n mesenteric vessel. Patient had 4litres EBL, patient transfuse 8 units\n PRBC while in Or, had 2 units FFP, and 2 Liters Lr. On arrival back to\n unit Patient given 2 units of platelets, 2 FFP and 1 Unit cryo.\n Levo continues at 0.1mcgs/kg to maintain map >60. Neo and vasopressin\n weaned off. remains open with wound packed and jp drain to\n suction.\n Response:\n Patients maintaining Map>60, hct monitored Q4 39.6-33.7, Jp draining\n large amounts of hemoserous fluid, team made aware.\n Plan:\n Instructed to monitor jp drainage and hct closely, will need further\n PRBCs transfusion to replace lost volume. Wean levo as tolerate.\n Electrolyte & fluid disorder, other\n Assessment:\n Patient had large blood loss, electrolytes monitored throughout day.\n Action:\n IV calcium chloride 2 amps and sodium bicarb replaced as ordered. Labs\n rechecked on return from OR Potassium low ( when patient in Or\n Potassium was high 6.5 they gave amp D50 and insulin) supplement given\n Mg and calcium also low, patient to get iv supplement as ordered.\n Response:\n tolerating iv electrolyte supplements\n Plan:\n To continue to monitor and treat accordingly.\n Family updated on patient\ns condition throughout day,\n" }, { "category": "Nursing", "chartdate": "2199-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558810, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain intermittently throughout shift.\n Action:\n Pt with fentanyl patch at 25mcg intact, pt given 15 mg MSIR X 2 for\n breakthrough pain\n Response:\n Pt able to sleep in long naps after additional pain med\n Plan:\n Monitor pain level, medicate as needed for comfort. ? increase fentanyl\n patch dose for better control.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557734, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\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: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\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: 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:\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 intubated on Cpap/PSV. @ 4am pt began spo2 began\n to drop on the low 90\ns @ times in the high 80\ns. pt is placed on full\n support. Plan to wean back to PSV when tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558098, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\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: No\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: Yellow / 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 extubated on high flow\n" }, { "category": "Nursing", "chartdate": "2199-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556920, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED.\n Chief complaint:\n abdominal pain\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Patient returned from or at @10am having had right colectomy for cdiff\n colitis. On arrival to unit patient intubated, on neo 1.5mcgs, patient\n had EBL 800, was given 4500 crystalloid, 3 FFP. 500 albumin.\n .H/O acidosis, Metabolic\n Assessment:\n repeat abg preformed Ph 7.01 -6.81, Patient became very hypotensive\n despite having iv neo 5mcgs. Levo .4mcgs and vasopressin at 2.4units\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n patient intubated, lungs clear but diminished. O2 sats 100% on 70%\n fio2. Abg preformed Ph 7.32, Pco2 39, Po2 227.\n Action:\n cxr obtain to check tube placement. Ett repositioned and advanced\n 1-2cm. Fio2 reduced to 40%. Pulmonary toileting preformed.\n Response:\n maintaining good gas exchange, lungs clear but diminished.\n Plan:\n to continue to monitor Abg\ns wean off vent when patient stable.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557057, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure monday\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 5. ABG due at 1700\n Response:\n No change in pt status. Post ABG\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr.\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt.\n" }, { "category": "Physician ", "chartdate": "2199-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 558849, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Fentanyl Patch 6.\n Gabapentin 7. Heparin\n 8. 9. Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl) 12.\n Metoprolol Tartrate 13. Metoprolol Tartrate\n 14. Morphine Sulfate IR 15. Neutra-Phos 16. Potassium Chloride 17.\n Sodium Chloride 0.9% Flush 18. Sodium Chloride 0.9% Flush\n 19. Sodium Phosphate 20. Vancomycin Oral Liquid\n 24 Hour Events:\n no acute events, pain management improved\n Post operative day:\n POD#10 - Subtotal colectomy\n POD#10 - exp lap and oversewing of messenteric vessel.\n POD#7 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:19 AM\n Metronidazole - 03:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:18 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: 36.8\nC (98.3\n HR: 73 (71 - 90) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (12 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 4 (1 - 11) mmHg\n Total In:\n 2,503 mL\n 657 mL\n PO:\n Tube feeding:\n 1,783 mL\n 436 mL\n IV Fluid:\n 470 mL\n 131 mL\n Blood products:\n Total out:\n 2,450 mL\n 680 mL\n Urine:\n 1,250 mL\n 580 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 53 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminished\n bilateral bases)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Follows simple commands, moves b/l upper extremities and is\n able to hold, occasionally spontaneously moves lower extremities but\n unable to hold, garbled speech\n Labs / Radiology\n 391 K/uL\n 8.9 g/dL\n 142 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.1 %\n 16.2 K/uL\n [image002.jpg]\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n 02:49 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n 16.2\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n 26.1\n Plt\n 354\n 346\n 391\n 399\n 391\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n 142\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:3.4 g/dL, LDH:203 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl gtt, started fentanyl patch 25mcg/hr,\n IR morphine prn pain, neurontin, pain overall improved\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: requires suctioning, but maintains airway and SpO2,\n pulmonary toilet, OOB to chair\n GI: s/p abdominal closure, abdomen soft, stool output no longer with\n large volumes\n Nutrition: tube feeds advanced to goal, refused S/S eval Will try\n again. ? change to G- feeding??\n Renal: continues with good UOP. off albumin now.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: IV flagyl/PO Vanco for CDiff. afebrile,\n leukocytosis.\n Lines/Tubes/Drains: foley, R IJ, aline, PIV. Remove R IJ and A- line\n Wounds: erythema inferior portion of wound.\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b consider starting back on coumadin for\n hx of DVT\n Consults: General Surgery\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:15 AM\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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2199-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 557981, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n lethargy\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 5. Famotidine 6. Fentanyl Citrate 7. Furosemide 8. HYDROmorphone\n (Dilaudid) 9. Heparin 10. Heparin Flush (10 units/ml)\n 11. Insulin 12. Magnesium Sulfate 13. MetRONIDAZOLE (FLagyl) 14.\n Potassium Chloride 15. Propofol\n 16. Sodium Chloride 0.9% Flush 17. Sodium Chloride 0.9% Flush 18.\n Vancomycin Oral Liquid\n 24 Hour Events:\n to OR for colectomy\n take back to OR for bleed\n : FFP, cut back on IVF\n : takeback for closure, off pressors, improving\n : weaning off ps\n : desat early am. suctioned and put on cmv and sats improved.\n throughout day pt more alert/interactive. attempt at thoracentesis for\n left pleural effusion aborted given no sign fluid removal, UOP\n increased\n Post operative day:\n POD#6 - Subtotal colectomy\n POD#6 - exp lap and oversewing of messenteric vessel.\n POD#3 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Vancomycin - 02:00 AM\n Metronidazole - 05:21 AM\n Infusions:\n Fentanyl - 175 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:39 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: 36.6\nC (97.9\n HR: 88 (74 - 111) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 10 (7 - 54) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.6 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 7 (2 - 11) mmHg\n Total In:\n 2,731 mL\n 1,031 mL\n PO:\n Tube feeding:\n 448 mL\n 384 mL\n IV Fluid:\n 1,458 mL\n 547 mL\n Blood products:\n 300 mL\n 100 mL\n Total out:\n 5,180 mL\n 2,370 mL\n Urine:\n 5,180 mL\n 2,270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,449 mL\n -1,339 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 676 (462 - 676) mL\n PS : 5 cmH2O\n RR (Spontaneous): 7\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 24\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.38/52/123/29/4\n Ve: 4.8 L/min\n PaO2 / FiO2: 308\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, Tender: over incision appropriately\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 219 K/uL\n 9.2 g/dL\n 93 mg/dL\n 0.4 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 3 mg/dL\n 110 mEq/L\n 146 mEq/L\n 26.2 %\n 15.4 K/uL\n [image002.jpg]\n 10:00 PM\n 03:10 AM\n 03:21 AM\n 04:55 AM\n 06:26 AM\n 08:26 AM\n 11:08 AM\n 05:19 PM\n 02:20 AM\n 02:35 AM\n WBC\n 12.9\n 15.4\n Hct\n 24.2\n 26.2\n Plt\n 148\n 219\n Creatinine\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 28\n 28\n 30\n 30\n 32\n Glucose\n 109\n 66\n 74\n 84\n 93\n Other labs: PT / PTT / INR:15.3/48.3/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:7.7 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt weaned, fentanyl gtt\n Cardiovascular: HD stable\n Pulmonary: wean vent as tolerated, spont breathing trial and possible\n extubation today\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n Nutrition: tube feeds advanced yesterday\n Renal: Will KVO as tolerated. UOP increased. Albumin 25 gm x3 on .\n diuresed 2.5L yesterday without lasix gtt\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: low grade temp, cdiff, Started on flagyl. PO Vanco\n started . zosyn d/ced .\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), low grade\n temp, cdiff, Started on flagyl. PO Vanco started . zosyn d/ced\n .\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids: Albumin\n Consults: General surgery\n Billing Diagnosis: Post-op complication, Peritonitis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558534, "text": "Hypertension, benign\n Assessment:\n Hx of benign htn, sys occas up to 160\n Action:\n pt on metoprolol via peg tube\n Response:\n sys presently 130\n Plan:\n Keep htn under control with beta blockers as ordered\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n pt has frequent respir secretions\n Action:\n nasopharyngeal suctioning x 2 today , chest pt, reposition frequently\n Response:\n small-moder thick white secretions\n Plan:\n continue to suction prn, chest pt q 2-3 hrs\n" }, { "category": "Physician ", "chartdate": "2199-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 558404, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n abdominal pain\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Duloxetine 5.\n Famotidine 6. Fentanyl Citrate\n 7. Furosemide 8. Gabapentin 9. Heparin 10. Insulin 11. Magnesium\n Sulfate 12. MetRONIDAZOLE (FLagyl)\n 13. Metoprolol Tartrate 14. Metoprolol Tartrate 15. Morphine Sulfate IR\n 16. Neutra-Phos 17. Potassium Chloride\n 18. Sodium Chloride 0.9% Flush 19. Sodium Chloride 0.9% Flush 20.\n Sodium Phosphate 21. Vancomycin Oral Liquid\n 24 Hour Events:\n to OR for colectomy\n take back to OR for bleed\n : FFP, cut back on IVF\n : takeback for closure, off pressors, improving\n : weaning off ps\n : desat early am. suctioned and put on cmv and sats improved.\n throughout day pt more alert/interactive. attempt at thoracentesis for\n left pleural effusion aborted given no sign fluid removal, UOP\n increased\n : refused speech/swallow, albumin and lasix given\n Post operative day:\n POD#8 - Subtotal colectomy\n POD#8 - exp lap and oversewing of messenteric vessel.\n POD#5 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:58 AM\n Metronidazole - 03:42 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 AM\n Metoprolol - 08:44 PM\n Furosemide (Lasix) - 11:04 PM\n Heparin Sodium (Prophylaxis) - 03:43 AM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 98 (85 - 116) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (13 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 5 (1 - 13) mmHg\n Total In:\n 3,128 mL\n 722 mL\n PO:\n Tube feeding:\n 1,686 mL\n 472 mL\n IV Fluid:\n 601 mL\n 250 mL\n Blood products:\n 200 mL\n Total out:\n 4,570 mL\n 1,900 mL\n Urine:\n 4,100 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,442 mL\n -1,178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///37/\n Physical Examination\n Gen: NAD, AAOx3\n HEENT: PEARL\n CV: RRR\n Pulm: CTA b/l\n Abd: soft, mildly distended, incision C/D/I, erythema unchanged\n Ext: + edema\n Labs / Radiology\n 346 K/uL\n 9.4 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 5 mg/dL\n 101 mEq/L\n 143 mEq/L\n 27.6 %\n 20.2 K/uL\n [image002.jpg]\n 05:19 PM\n 02:20 AM\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n WBC\n 15.4\n 21.3\n 20.2\n Hct\n 26.2\n 30.1\n 27.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.3\n 0.3\n 0.4\n 0.4\n TCO2\n 32\n 33\n 32\n 35\n Glucose\n 84\n 93\n 112\n 186\n 166\n 154\n Other labs: PT / PTT / INR:15.1/37.0/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl, titrating up morphine for pain,\n restarted neurontin\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: pulmonary toilet\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: lasix and albumin given yesterday, cont with goal 2 liters neg.\n Aggressive phosphate repletion\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: IV flagyl/PO Vanco for CDiff, low grade temps and\n cont elevated wbc. Consider d/cing if continues. Monitor wound\n for erythema.\n Lines / Tubes / Drains: Foley, NGT, , \n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Post-op shock\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:06 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 557114, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. 1000 mL LR 6. Calcium Gluconate 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Famotidine 9. Fentanyl Citrate 10. HYDROmorphone (Dilaudid) 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. Hydrocortisone Na Succ. 14. Insulin 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Norepinephrine 19. Piperacillin-Tazobactam Na 20. Potassium\n Chloride 21. Sodium Chloride 0.9% Flush\n 22. Sodium Chloride 0.9% Flush 23. Vancomycin Enema\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n OR RECEIVED - At 09:46 AM\n MULTI LUMEN - START 01:00 PM\n Received FFP, off pressors\n Post operative day:\n POD#2 - Subtotal colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Metronidazole - 02:21 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 05:46 PM\n Heparin Sodium (Prophylaxis) - 10:50 PM\n Other medications:\n Flowsheet Data as of 03:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.9\nC (98.5\n HR: 75 (75 - 96) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 0 (0 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 8 (5 - 16) mmHg\n Total In:\n 7,539 mL\n 723 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,995 mL\n 723 mL\n Blood products:\n 544 mL\n Total out:\n 2,990 mL\n 315 mL\n Urine:\n 810 mL\n 115 mL\n NG:\n 100 mL\n Stool:\n Drains:\n 2,050 mL\n 200 mL\n Balance:\n 4,549 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 514 (514 - 514) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 99%\n ABG: 7.43/43/126/27/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases and RUL)\n Abdominal: Soft\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 96 K/uL\n 9.8 g/dL\n 79 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 118 mEq/L\n 148 mEq/L\n 26.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:51 PM\n 09:49 PM\n 01:08 AM\n 03:09 AM\n 05:33 AM\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n WBC\n 5.8\n 7.6\n 7.4\n 10.1\n Hct\n 32.9\n 32.5\n 28.1\n 26.3\n Plt\n 88\n 97\n 96\n 96\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 15\n 13\n 20\n 24\n 27\n 29\n Glucose\n 166\n 147\n 93\n 79\n Other labs: PT / PTT / INR:19.7/40.2/1.8, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:628/750, Alk-Phos / T bili:27/0.5,\n Fibrinogen:159 mg/dL, Lactic Acid:2.3 mmol/L, Albumin:1.3 g/dL,\n LDH:1400 IU/L, Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip\n Cardiovascular: HD stable over night, MAP>60 as goal. Cont\n resuscitation, off pressors\n Pulmonary: Intubated, wean vent as tolerated\n Gastrointestinal/Abdominal: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: monitor uop\n Hematology: f/u serial cbc and coags, HCT slowing drifting down,\n maintains dilute blood tinged output via abd drains\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn. vancomycin\n Lines/Tubes/Drains: foley, R IJ, aline, JP. d/c femoral line?\n Wounds: open abd wound, bilateral gluteal stage 2 pressure ulcers,\n first step bed ordered, wound care consult\n Imaging: none\n Fluids: LR @ 100 ml/hr\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 558818, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Fentanyl Patch 6.\n Gabapentin 7. Heparin\n 8. 9. Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl) 12.\n Metoprolol Tartrate 13. Metoprolol Tartrate\n 14. Morphine Sulfate IR 15. Neutra-Phos 16. Potassium Chloride 17.\n Sodium Chloride 0.9% Flush 18. Sodium Chloride 0.9% Flush\n 19. Sodium Phosphate 20. Vancomycin Oral Liquid\n 24 Hour Events:\n no acute events, pain management improved\n Post operative day:\n POD#10 - Subtotal colectomy\n POD#10 - exp lap and oversewing of messenteric vessel.\n POD#7 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:19 AM\n Metronidazole - 03:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:18 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: 36.8\nC (98.3\n HR: 73 (71 - 90) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (12 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 4 (1 - 11) mmHg\n Total In:\n 2,503 mL\n 657 mL\n PO:\n Tube feeding:\n 1,783 mL\n 436 mL\n IV Fluid:\n 470 mL\n 131 mL\n Blood products:\n Total out:\n 2,450 mL\n 680 mL\n Urine:\n 1,250 mL\n 580 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 53 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminished\n bilateral bases)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Follows simple commands, moves b/l upper extremities and is\n able to hold, occasionally spontaneously moves lower extremities but\n unable to hold, garbled speech\n Labs / Radiology\n 391 K/uL\n 8.9 g/dL\n 142 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.1 %\n 16.2 K/uL\n [image002.jpg]\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n 02:49 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n 16.2\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n 26.1\n Plt\n 354\n 346\n 391\n 399\n 391\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n 142\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:3.4 g/dL, LDH:203 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl gtt, started fentanyl patch 25mcg/hr,\n IR morphine prn pain, neurontin, pain overall improved\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: requires suctioning, but maintains airway and SpO2,\n pulmonary toilet, OOB to chair\n GI: s/p abdominal closure, abdomen soft, stool output no longer with\n large volumes\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: continues with good UOP. off albumin now.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: IV flagyl/PO Vanco for CDiff. afebrile,\n leukocytosis.\n Lines/Tubes/Drains: foley, R IJ, aline, PIV. Remove R IJ\n Wounds: erythema inferior portion of wound.\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Surgery\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:15 AM\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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2199-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 557962, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n respiratory distress, colectomy\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 5. Dextrose 50% 6. Dextrose 50% 7. Famotidine 8. Fentanyl Citrate 9.\n Heparin 10. Heparin Flush (10 units/ml)\n 11. Insulin 12. Magnesium Sulfate 13. MetRONIDAZOLE (FLagyl) 14.\n Potassium Chloride 15. Propofol\n 16. Sodium Chloride 0.9% Flush 17. Sodium Chloride 0.9% Flush 18.\n Vancomycin Oral Liquid\n 24 Hour Events:\n desat overnight. suctioned and put on cmv. sats improved.\n Post operative day:\n POD#5 - Subtotal colectomy\n POD#5 - exp lap and oversewing of messenteric vessel.\n POD#2 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Metronidazole - 04:00 AM\n Vancomycin - 08:01 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Fentanyl - 09:30 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Dextrose 50% - 04:30 AM\n Famotidine (Pepcid) - 08:01 AM\n Other medications:\n Flowsheet Data as of 08:24 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: 36.9\nC (98.4\n HR: 89 (69 - 100) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 18 (6 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 9 (2 - 15) mmHg\n Total In:\n 2,362 mL\n 1,152 mL\n PO:\n Tube feeding:\n 60 mL\n 83 mL\n IV Fluid:\n 1,752 mL\n 645 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 2,370 mL\n 1,300 mL\n Urine:\n 1,870 mL\n 1,300 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -8 mL\n -148 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (400 - 500) mL\n Vt (Spontaneous): 667 (536 - 788) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/42/154/28/3\n Ve: 9 L/min\n PaO2 / FiO2: 385\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 148 K/uL\n 8.3 g/dL\n 66 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 111 mEq/L\n 144 mEq/L\n 24.2 %\n 12.9 K/uL\n [image002.jpg]\n 07:39 AM\n 12:53 PM\n 01:03 PM\n 07:18 PM\n 09:00 PM\n 10:00 PM\n 03:10 AM\n 03:21 AM\n 04:55 AM\n 06:26 AM\n WBC\n 12.9\n Hct\n 24.2\n Plt\n 148\n Creatinine\n 0.5\n 0.5\n 0.5\n TCO2\n 26\n 27\n 30\n 28\n 28\n Glucose\n 70\n 65\n 124\n 109\n 66\n Other labs: PT / PTT / INR:14.6/49.1/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:7.5 mg/dL, Mg:2.0 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt, fentanyl gtt\n Cardiovascular: HD stable, off pressors\n Pulmonary: wean vent as tolerated\n consider thoracentesis for effusion\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft,\n bladder pressures normal\n Nutrition: Trophic feeds today\n Renal: takes lasix at home. Will KVO as tolerated. UOP adequate.\n Albumin 25 gm x3 on .\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl. PO Vanco started .\n zosyn d/ced .\n Lines / Tubes / Drains: foley, R IJ, aline, JP.\n Wounds: wet to dry\n Imaging:\n Fluids: Albumin\n Consults: General surgery\n Billing Diagnosis: (Respiratory failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36\n" }, { "category": "Physician ", "chartdate": "2199-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 558413, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n abdominal pain\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. Albumin 25% (12.5g / 50mL) 3. Calcium Gluconate 4. Duloxetine 5.\n Famotidine 6. Fentanyl Citrate\n 7. Furosemide 8. Gabapentin 9. Heparin 10. Insulin 11. Magnesium\n Sulfate 12. MetRONIDAZOLE (FLagyl)\n 13. Metoprolol Tartrate 14. Metoprolol Tartrate 15. Morphine Sulfate IR\n 16. Neutra-Phos 17. Potassium Chloride\n 18. Sodium Chloride 0.9% Flush 19. Sodium Chloride 0.9% Flush 20.\n Sodium Phosphate 21. Vancomycin Oral Liquid\n 24 Hour Events:\n to OR for colectomy\n take back to OR for bleed\n : FFP, cut back on IVF\n : takeback for closure, off pressors, improving\n : weaning off ps\n : desat early am. suctioned and put on cmv and sats improved.\n throughout day pt more alert/interactive. attempt at thoracentesis for\n left pleural effusion aborted given no sign fluid removal, UOP\n increased\n : refused speech/swallow, albumin and lasix given\n Post operative day:\n POD#8 - Subtotal colectomy\n POD#8 - exp lap and oversewing of messenteric vessel.\n POD#5 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:58 AM\n Metronidazole - 03:42 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 AM\n Metoprolol - 08:44 PM\n Furosemide (Lasix) - 11:04 PM\n Heparin Sodium (Prophylaxis) - 03:43 AM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 98 (85 - 116) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (13 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 5 (1 - 13) mmHg\n Total In:\n 3,128 mL\n 722 mL\n PO:\n Tube feeding:\n 1,686 mL\n 472 mL\n IV Fluid:\n 601 mL\n 250 mL\n Blood products:\n 200 mL\n Total out:\n 4,570 mL\n 1,900 mL\n Urine:\n 4,100 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,442 mL\n -1,178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///37/\n Physical Examination\n Gen: NAD, AAOx3\n HEENT: PEARL\n CV: RRR\n Pulm: CTA b/l\n Abd: soft, mildly distended, incision C/D/I, erythema unchanged\n Ext: + edema\n Labs / Radiology\n 346 K/uL\n 9.4 g/dL\n 154 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 5 mg/dL\n 101 mEq/L\n 143 mEq/L\n 27.6 %\n 20.2 K/uL\n [image002.jpg]\n 05:19 PM\n 02:20 AM\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n WBC\n 15.4\n 21.3\n 20.2\n Hct\n 26.2\n 30.1\n 27.6\n Plt\n \n Creatinine\n 0.4\n 0.4\n 0.3\n 0.3\n 0.4\n 0.4\n TCO2\n 32\n 33\n 32\n 35\n Glucose\n 84\n 93\n 112\n 186\n 166\n 154\n Other labs: PT / PTT / INR:15.1/37.0/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: wean off fentanyl, titrating up morphine for pain,\n restarted neurontin\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: pulmonary toilet\n Gastrointestinal / Abdomen: s/p abdominal closure, abdomen soft\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: lasix and albumin given yesterday, cont with goal 2 liters neg.\n Aggressive phosphate repletion\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: IV flagyl/PO Vanco for CDiff, low grade temps and\n cont elevated wbc. Consider d/cing if continues. Monitor wound\n for erythema.\n Lines / Tubes / Drains: Foley, NGT, , \n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Post-op shock\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:06 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 557110, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. 1000 mL LR 6. Calcium Gluconate 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Famotidine 9. Fentanyl Citrate 10. HYDROmorphone (Dilaudid) 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. Hydrocortisone Na Succ. 14. Insulin 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Norepinephrine 19. Piperacillin-Tazobactam Na 20. Potassium\n Chloride 21. Sodium Chloride 0.9% Flush\n 22. Sodium Chloride 0.9% Flush 23. Vancomycin Enema\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n OR RECEIVED - At 09:46 AM\n MULTI LUMEN - START 01:00 PM\n Received FFP, off pressors\n Post operative day:\n POD#2 - Subtotal colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Metronidazole - 02:21 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 05:46 PM\n Heparin Sodium (Prophylaxis) - 10:50 PM\n Other medications:\n Flowsheet Data as of 03:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.9\nC (98.5\n HR: 75 (75 - 96) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 0 (0 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 8 (5 - 16) mmHg\n Total In:\n 7,539 mL\n 723 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,995 mL\n 723 mL\n Blood products:\n 544 mL\n Total out:\n 2,990 mL\n 315 mL\n Urine:\n 810 mL\n 115 mL\n NG:\n 100 mL\n Stool:\n Drains:\n 2,050 mL\n 200 mL\n Balance:\n 4,549 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 514 (514 - 514) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 99%\n ABG: 7.43/43/126/27/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases and RUL)\n Abdominal: Soft\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 96 K/uL\n 9.8 g/dL\n 79 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 118 mEq/L\n 148 mEq/L\n 26.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:51 PM\n 09:49 PM\n 01:08 AM\n 03:09 AM\n 05:33 AM\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n WBC\n 5.8\n 7.6\n 7.4\n 10.1\n Hct\n 32.9\n 32.5\n 28.1\n 26.3\n Plt\n 88\n 97\n 96\n 96\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 15\n 13\n 20\n 24\n 27\n 29\n Glucose\n 166\n 147\n 93\n 79\n Other labs: PT / PTT / INR:19.7/40.2/1.8, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:628/750, Alk-Phos / T bili:27/0.5,\n Fibrinogen:159 mg/dL, Lactic Acid:2.3 mmol/L, Albumin:1.3 g/dL,\n LDH:1400 IU/L, Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip\n Cardiovascular: HD stable over night, MAP>60 as goal. Cont\n resuscitation, off pressors\n Pulmonary: Intubated, wean vent as tolerated\n Gastrointestinal/Abdominal: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: monitor uop\n Hematology: f/u serial cbc and coags, HCT slowing drifting down,\n maintains dilute blood tinged output via abd drains\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn. vancomycin\n Lines/Tubes/Drains: foley, R IJ, aline, JP. d/c femoral line?\n Wounds: open abd wound\n Imaging: none\n Fluids: LR @ 100 ml/hr\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557167, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure Monday\n Wound care consult placed\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcer on right and left gluteral area. Skin tear on coccyx.\n Action:\n Turned q2hrs, mepiflex dsg intact. Bed company needs to be called for\n step one mattresss.\n Response:\n No change with dsg on coccyx intact.\n Plan:\n Continue to turn q2hrs, dsg to remain intact for 3days thereafter\n change place on one step mattress. Confer with wound nurse\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Levophed gtt remains off wilth bpmean > 60. hct 26. plts 96.\n comfortable on iv fentanyl and versed gtts/ for pain control and\n comfort.\n Action:\n Lactated ringers at 100cc/hr. magnesium and potassium iv repleted. Iv\n fentanyl and versed infusing. Suction prn. Cardiac output/ index and\n svr via vigelleo. Labs prn. Remains vented and abg done. Abd remains\n open with jp drain to suction.\n Response:\n Stable post op\n Plan:\n Monitor condition closely to or on Monday for abd closure.\n" }, { "category": "Physician ", "chartdate": "2199-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 557180, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. 1000 mL LR 6. Calcium Gluconate 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Famotidine 9. Fentanyl Citrate 10. HYDROmorphone (Dilaudid) 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. Hydrocortisone Na Succ. 14. Insulin 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Norepinephrine 19. Piperacillin-Tazobactam Na 20. Potassium\n Chloride 21. Sodium Chloride 0.9% Flush\n 22. Sodium Chloride 0.9% Flush 23. Vancomycin Enema\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n OR RECEIVED - At 09:46 AM\n MULTI LUMEN - START 01:00 PM\n Received FFP, off pressors\n Post operative day:\n POD#2 - Subtotal colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Metronidazole - 02:21 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 05:46 PM\n Heparin Sodium (Prophylaxis) - 10:50 PM\n Other medications:\n Flowsheet Data as of 03:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.9\nC (98.5\n HR: 75 (75 - 96) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 0 (0 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 8 (5 - 16) mmHg\n Total In:\n 7,539 mL\n 723 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,995 mL\n 723 mL\n Blood products:\n 544 mL\n Total out:\n 2,990 mL\n 315 mL\n Urine:\n 810 mL\n 115 mL\n NG:\n 100 mL\n Stool:\n Drains:\n 2,050 mL\n 200 mL\n Balance:\n 4,549 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 514 (514 - 514) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 99%\n ABG: 7.43/43/126/27/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases and RUL)\n Abdominal: Soft\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 96 K/uL\n 9.8 g/dL\n 79 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 118 mEq/L\n 148 mEq/L\n 26.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:51 PM\n 09:49 PM\n 01:08 AM\n 03:09 AM\n 05:33 AM\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n WBC\n 5.8\n 7.6\n 7.4\n 10.1\n Hct\n 32.9\n 32.5\n 28.1\n 26.3\n Plt\n 88\n 97\n 96\n 96\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 15\n 13\n 20\n 24\n 27\n 29\n Glucose\n 166\n 147\n 93\n 79\n Other labs: PT / PTT / INR:19.7/40.2/1.8, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:628/750, Alk-Phos / T bili:27/0.5,\n Fibrinogen:159 mg/dL, Lactic Acid:2.3 mmol/L, Albumin:1.3 g/dL,\n LDH:1400 IU/L, Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip\n Cardiovascular: HD stable over night, MAP>60 as goal. Cont\n resuscitation, off pressors\n Pulmonary: Intubated, wean vent as tolerated\n Gastrointestinal/Abdominal: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: monitor uop\n Hematology: f/u serial cbc and coags, HCT slowing drifting down,\n maintains dilute blood tinged output via abd drains\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn. vancomycin\n Lines/Tubes/Drains: foley, R IJ, aline, JP. d/c femoral line?\n Wounds: open abd wound, bilateral gluteal stage 2 pressure ulcers,\n first step bed ordered, wound care consult\n Imaging: none\n Fluids: LR @ 100 ml/hr\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558731, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt potassium level 3.4 from 1700, mag level 1.7 at 1700. Pt continues\n to be positive from LOS cumulative\n Action:\n Pt repleted electrolytes as per orders\n Response:\n Electrolytes improved after repletion. Pt continued to autodiurese\n approximately 200cc or more an hour\n Plan:\n Follow labs, replete PRN. Follow I/Os with goal to keep negative\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated, pox 98-100%. LS clear but diminished at bases\n Action:\n ABGs monitored\n Response:\n Pt\ns vent settings changed to CPAP 5 peep, 10PS\n Plan:\n Continue to follow ABGs, pox and respiratory assessments. Wean settings\n as tolerated with goal to extubate when pt is able\n" }, { "category": "Physician ", "chartdate": "2199-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 557556, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. 1000 mL LR 3. Calcium Gluconate 4. Chlorhexidine Gluconate 0.12%\n Oral Rinse 5. Famotidine\n 6. Fentanyl Citrate 7. Heparin 8. Heparin Flush (10 units/ml) 9.\n Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl)\n 12. Piperacillin-Tazobactam Na 13. Potassium Chloride 14. Propofol 15.\n Sodium Chloride 0.9% Flush\n 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR SENT - At 08:38 AM\n patient went to OR to have wound closed\n OR RECEIVED - At 11:00 AM\n MULTI LUMEN - STOP 01:00 PM\n takeback for closure, off pressors, improving\n Post operative day:\n POD#4 - Subtotal colectomy\n POD#4 - exp lap and oversewing of messenteric vessel.\n POD#1 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 06:09 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Fentanyl - 12:08 AM\n Dextrose 50% - 04:11 AM\n Heparin Sodium (Prophylaxis) - 06:09 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 95 (61 - 98) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (0 - 30) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 4 (0 - 8) mmHg\n Bladder pressure: 10 (10 - 10) mmHg\n Total In:\n 3,242 mL\n 481 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,630 mL\n 456 mL\n Blood products:\n 612 mL\n Total out:\n 2,230 mL\n 300 mL\n Urine:\n 1,150 mL\n 300 mL\n NG:\n Stool:\n Drains:\n 600 mL\n Balance:\n 1,012 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 10\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 49\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.45/39/115/26/3\n Ve: 67.3 L/min\n PaO2 / FiO2: 287\n Physical Examination\n General Appearance: No acute distress\n HEENT: intubated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases bilaterally)\n Abdominal: Soft\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 145 K/uL\n 9.4 g/dL\n 59 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 115 mEq/L\n 150 mEq/L\n 27.0 %\n 11.4 K/uL\n [image002.jpg]\n 04:22 AM\n 09:35 AM\n 06:04 PM\n 06:21 PM\n 03:07 AM\n 12:34 PM\n 12:40 PM\n 06:13 PM\n 07:15 PM\n 03:06 AM\n WBC\n 10.9\n 10.8\n 11.4\n 12.2\n 12.1\n 11.4\n Hct\n 26.7\n 27.7\n 26.8\n 28.5\n 26.5\n 27.0\n Plt\n 95\n 86\n 89\n 99\n 115\n 145\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 27\n 25\n 28\n Glucose\n 84\n 80\n 72\n 90\n 75\n 59\n Other labs: PT / PTT / INR:15.7/39.8/1.4, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:289/198, Alk-Phos / T bili:30/1.4,\n Fibrinogen:432 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:1.3 g/dL, LDH:188\n IU/L, Ca:7.4 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt, intermittent fentanyl prn\n Cardiovascular: HD stable, off pressors\n Pulmonary: wean vent as tolerated\n GI: s/p abdominal closure, abdomen soft, bladder pressures normal\n Nutrition: NPO. consider trophic feeds today.\n Renal: takes lasix at home. Will KVO as tolerated. UOP adequate.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn.\n Lines/Tubes/Drains: foley, R IJ, aline, JP.\n Wounds: wet to dry\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2199-02-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 557245, "text": "Subjective\n Pt intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 70 kg\n 25.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 109\n Diagnosis: Sepsis\n PMH :\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT ,s/p lap\n chole , s/p INH as child, Hip surgery\n Food allergies and intolerances:\n Pertinent medications: Noted\n Labs:\n Value\n Date\n Glucose\n 84 mg/dL\n 09:35 AM\n Glucose Finger Stick\n 100\n 04:00 PM\n BUN\n 16 mg/dL\n 09:35 AM\n Creatinine\n 0.5 mg/dL\n 09:35 AM\n Sodium\n 146 mEq/L\n 09:35 AM\n Potassium\n 4.0 mEq/L\n 09:35 AM\n Chloride\n 116 mEq/L\n 09:35 AM\n TCO2\n 26 mEq/L\n 09:35 AM\n PO2 (arterial)\n 119 mm Hg\n 04:22 AM\n PCO2 (arterial)\n 39 mm Hg\n 04:22 AM\n pH (arterial)\n 7.44 units\n 04:22 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:22 AM\n Albumin\n 1.3 g/dL\n 03:00 PM\n Calcium non-ionized\n 7.5 mg/dL\n 09:35 AM\n Phosphorus\n 2.1 mg/dL\n 09:35 AM\n Ionized Calcium\n 1.20 mmol/L\n 04:22 AM\n Magnesium\n 2.3 mg/dL\n 09:35 AM\n ALT\n 289 IU/L\n 04:10 AM\n Alkaline Phosphate\n 30 IU/L\n 04:10 AM\n AST\n 198 IU/L\n 04:10 AM\n Total Bilirubin\n 1.4 mg/dL\n 04:10 AM\n WBC\n 10.9 K/uL\n 09:35 AM\n Hgb\n 9.9 g/dL\n 09:35 AM\n Hematocrit\n 26.7 %\n 09:35 AM\n Current diet order / nutrition support: NPO\n GI: Abd open/(-)BS/ (-) flatus\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, recent surgery, needs nutrition support\n Estimated Nutritional Needs based on adm wt\n Calories: 1750-2100kcals/day (25-30kcal/kg)\n Protein: 84-105g/day (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Tube feeding / TPN recommendations:\n Check triglycerides\n" }, { "category": "Physician ", "chartdate": "2199-02-11 00:00:00.000", "description": "Intensivist Note", "row_id": 558800, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n Calcium Gluconate 3. Duloxetine 4. Famotidine 5. Fentanyl Patch 6.\n Gabapentin 7. Heparin\n 8. 9. Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl) 12.\n Metoprolol Tartrate 13. Metoprolol Tartrate\n 14. Morphine Sulfate IR 15. Neutra-Phos 16. Potassium Chloride 17.\n Sodium Chloride 0.9% Flush 18. Sodium Chloride 0.9% Flush\n 19. Sodium Phosphate 20. Vancomycin Oral Liquid\n 24 Hour Events:\n no acute events, pain management improved\n Post operative day:\n POD#10 - Subtotal colectomy\n POD#10 - exp lap and oversewing of messenteric vessel.\n POD#7 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:19 AM\n Metronidazole - 03:44 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:18 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: 36.8\nC (98.3\n HR: 73 (71 - 90) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (12 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 4 (1 - 11) mmHg\n Total In:\n 2,503 mL\n 657 mL\n PO:\n Tube feeding:\n 1,783 mL\n 436 mL\n IV Fluid:\n 470 mL\n 131 mL\n Blood products:\n Total out:\n 2,450 mL\n 680 mL\n Urine:\n 1,250 mL\n 580 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 53 mL\n -23 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Follows simple commands\n Labs / Radiology\n 391 K/uL\n 8.9 g/dL\n 142 mg/dL\n 0.3 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.1 %\n 16.2 K/uL\n [image002.jpg]\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n 04:40 PM\n 02:52 AM\n 12:18 AM\n 04:14 AM\n 02:49 AM\n WBC\n 21.3\n 20.2\n 20.2\n 19.5\n 16.2\n Hct\n 30.1\n 27.6\n 28.7\n 27.0\n 26.1\n Plt\n 354\n 346\n 391\n 399\n 391\n Creatinine\n 0.3\n 0.3\n 0.4\n 0.4\n 0.3\n 0.3\n 0.3\n TCO2\n 33\n 32\n 35\n Glucose\n 112\n 186\n 166\n 154\n 141\n 195\n 142\n Other labs: PT / PTT / INR:13.8/33.0/1.2, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Differential-Neuts:88.0 %, Band:1.0 %, Lymph:2.0 %,\n Mono:4.0 %, Eos:2.0 %, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L,\n Albumin:3.4 g/dL, LDH:203 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN,\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), DECUBITUS ULCER (PRESENT AT\n ADMISSION), .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER,\n OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE\n RENAL FAILURE, ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: weaned off fentanyl gtt, started fentanyl patch 25mcg/hr,\n IR morphine prn pain, neurontin, pain overall improved\n Cardiovascular: lop 25 tid, Lop 5 IV Q4 prn\n Pulmonary: requires suctioning, but maintains airway and SpO2,\n pulmonary toilet, OOB to chair\n GI: s/p abdominal closure, abdomen soft, stool output no longer with\n large volumes\n Nutrition: tube feeds advanced to goal, refused S/S eval\n Renal: continues with good UOP. off albumin now.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: IV flagyl/PO Vanco for CDiff. afebrile,\n leukocytosis.\n Lines/Tubes/Drains: foley, R IJ, aline, PIV.\n Wounds: erythema inferior portion of wound.\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Surgery\n Disposition: floor\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 PM\n 20 Gauge - 05:15 AM\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 Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2199-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 557620, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1. 2. 1000 mL LR 3. Calcium Gluconate 4. Chlorhexidine Gluconate 0.12%\n Oral Rinse 5. Famotidine\n 6. Fentanyl Citrate 7. Heparin 8. Heparin Flush (10 units/ml) 9.\n Insulin 10. Magnesium Sulfate 11. MetRONIDAZOLE (FLagyl)\n 12. Piperacillin-Tazobactam Na 13. Potassium Chloride 14. Propofol 15.\n Sodium Chloride 0.9% Flush\n 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR SENT - At 08:38 AM\n patient went to OR to have wound closed\n OR RECEIVED - At 11:00 AM\n MULTI LUMEN - STOP 01:00 PM\n takeback for closure, off pressors, improving\n Post operative day:\n POD#4 - Subtotal colectomy\n POD#4 - exp lap and oversewing of messenteric vessel.\n POD#1 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Metronidazole - 06:09 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Fentanyl - 12:08 AM\n Dextrose 50% - 04:11 AM\n Heparin Sodium (Prophylaxis) - 06:09 AM\n Other medications:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.6\nC (97.8\n HR: 95 (61 - 98) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (0 - 30) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 4 (0 - 8) mmHg\n Bladder pressure: 10 (10 - 10) mmHg\n Total In:\n 3,242 mL\n 481 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,630 mL\n 456 mL\n Blood products:\n 612 mL\n Total out:\n 2,230 mL\n 300 mL\n Urine:\n 1,150 mL\n 300 mL\n NG:\n Stool:\n Drains:\n 600 mL\n Balance:\n 1,012 mL\n 181 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 10\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 49\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.45/39/115/26/3\n Ve: 67.3 L/min\n PaO2 / FiO2: 287\n Physical Examination\n General Appearance: No acute distress\n HEENT: intubated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases bilaterally)\n Abdominal: Soft, Non-tender, non-distended\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No movement of lower ext\ns, minimally move upper ext\n Sedated ,Follows commands.\n Labs / Radiology\n 145 K/uL\n 9.4 g/dL\n 59 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 115 mEq/L\n 150 mEq/L\n 27.0 %\n 11.4 K/uL\n [image002.jpg]\n 04:22 AM\n 09:35 AM\n 06:04 PM\n 06:21 PM\n 03:07 AM\n 12:34 PM\n 12:40 PM\n 06:13 PM\n 07:15 PM\n 03:06 AM\n WBC\n 10.9\n 10.8\n 11.4\n 12.2\n 12.1\n 11.4\n Hct\n 26.7\n 27.7\n 26.8\n 28.5\n 26.5\n 27.0\n Plt\n 95\n 86\n 89\n 99\n 115\n 145\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 27\n 27\n 25\n 28\n Glucose\n 84\n 80\n 72\n 90\n 75\n 59\n Other labs: PT / PTT / INR:15.7/39.8/1.4, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:289/198, Alk-Phos / T bili:30/1.4,\n Fibrinogen:432 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:1.3 g/dL, LDH:188\n IU/L, Ca:7.4 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: propofol gtt, intermittent fentanyl prn\n Cardiovascular: HD stable, off pressors\n Pulmonary: wean vent as tolerated\n GI: s/p abdominal closure, abdomen soft, bladder pressures normal\n Nutrition: NPO. consider trophic feeds today.\n Renal: takes lasix at home\n will hold for now given hypernatremia and\n start albumin TID and follow UOP and Na.\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn.\n Lines/Tubes/Drains: foley, R IJ, aline, JP.\n Wounds: wet to dry\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis: Respiratory Failure.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557833, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with episode of hypoxia overnight when on CPAP, again this am when\n tried on CPAP pt not breathing adequately.\n Action:\n Kept on A/C for most of day, eventually weaned off Propofol and now\n back to CPAP.\n Response:\n Pt tolerating CPAP well, acceptable abg, moving good volumes, LS clear\n to upper lobes, dim to bases.\n Plan:\n Continue on CPAP as tolerated, if remains stable may be extubated in\n am.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt with large amount of fluid resuscitation after OR, large amount of\n general edema.\n Action:\n Pt written for Lasix gtt.\n Response:\n Pt began to auto diurese at rate of 200-300cc/hr. Lasix gtt not started\n as yet.\n Plan:\n Pt to be 2 liters negative for the day, is already 1700cc negative at\n 16:00.\n" }, { "category": "Nursing", "chartdate": "2199-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558151, "text": "Electrolyte & fluid disorder, other\n Assessment:\n 1600 labs reflecting low K+ and mag levels, pt. auto-diuresing and 2+ L\n negative by 2400.\n Action:\n Repleted w/40meq KCL and 2mg Mag IV.\n Response:\n Am labs pending.\n Plan:\n Cont. to monitor I/Os and labs.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Allevyn dressing intact to coccyx , dated . Gluteal areas healed.\n Action:\n Turned and repositioned q2hours, pt. on First Step mattresss.\n Response:\n Healing pressure ulcers to glutes, coccyx dressing intact.\n Plan:\n Cont. vigilant skin care, change dressing tomorrow and PRN,\n turning/repositioning q2hours, cont. TFs to optimize nutritional\n status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaned to 40-50% cool neb w/open face tent. Sats 98-100%. Lung sounds\n w/rhonchi throughout. Weak cough, raising thick sputum\n w/encouragement.\n Action:\n Frequent turning, encouraged to cough and deep breathe, HOB >30 for\n asp. Precautions.\n Response:\n Improving resp. status, pt. maintaining airway and able to raise\n secretions.\n Plan:\n Cont. aggressive pulm. Hygiene, wean 02 as tolerarated.\n" }, { "category": "Nursing", "chartdate": "2199-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558153, "text": "Hypertension, benign\n Assessment:\n SBP 170-185, HR 90-110. Pt. c/o pain at the time as well, nodding yes\n to ?s re. pain.\n Action:\n Lopressor 5mg IV q4hours ordered, Hydralazine 10mg IV x1 w/effect.\n Fentanyl gtt increased to 100mcg again and MSIR ordered for increased\n pain control.\n Response:\n SBP 150-160s after meds given. Less tachy after beta blocker and pain\n med given. Nodding yes to pain relief.\n Plan:\n Cont. to monitor pain , Lopressor ATC, Hydralazine PRN.\n" }, { "category": "Nutrition", "chartdate": "2199-02-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 557246, "text": "Subjective\n Pt intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 70 kg\n 25.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 109\n Diagnosis: Sepsis\n PMH : Hypertension,CVA: bilateral embolic cerebellar ,aphasia,\n hemorrhagic left thalamic , Type II Diabetes mellitus, Peripheral\n neuropathy , Constipation, Dysphagia, Depression, Hypothyroidism h/o\n DVT ,s/p lap chole , s/p INH as child, Hip surgery\n Food allergies and intolerances:\n Pertinent medications: Noted\n Labs:\n Value\n Date\n Glucose\n 84 mg/dL\n 09:35 AM\n Glucose Finger Stick\n 100\n 04:00 PM\n BUN\n 16 mg/dL\n 09:35 AM\n Creatinine\n 0.5 mg/dL\n 09:35 AM\n Sodium\n 146 mEq/L\n 09:35 AM\n Potassium\n 4.0 mEq/L\n 09:35 AM\n Chloride\n 116 mEq/L\n 09:35 AM\n TCO2\n 26 mEq/L\n 09:35 AM\n PO2 (arterial)\n 119 mm Hg\n 04:22 AM\n PCO2 (arterial)\n 39 mm Hg\n 04:22 AM\n pH (arterial)\n 7.44 units\n 04:22 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 04:22 AM\n Albumin\n 1.3 g/dL\n 03:00 PM\n Calcium non-ionized\n 7.5 mg/dL\n 09:35 AM\n Phosphorus\n 2.1 mg/dL\n 09:35 AM\n Ionized Calcium\n 1.20 mmol/L\n 04:22 AM\n Magnesium\n 2.3 mg/dL\n 09:35 AM\n ALT\n 289 IU/L\n 04:10 AM\n Alkaline Phosphate\n 30 IU/L\n 04:10 AM\n AST\n 198 IU/L\n 04:10 AM\n Total Bilirubin\n 1.4 mg/dL\n 04:10 AM\n WBC\n 10.9 K/uL\n 09:35 AM\n Hgb\n 9.9 g/dL\n 09:35 AM\n Hematocrit\n 26.7 %\n 09:35 AM\n Current diet order / nutrition support: NPO\n GI: Abd open/(-)BS/ (-) flatus\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO, recent surgery, needs nutrition support\n Estimated Nutritional Needs based on adm wt\n Calories: 1750-2100kcals/day (25-30kcal/kg)\n Protein: 84-105g/day (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate\n Specifics:\n 62 yo Spanish speaking M p/w HoTN and lethargy. Pt had recent admision\n for pneumosepsis. s/p subtotal colectomy w ileostomy and\n takeback for bleeding , POD #2, plan for abd closure tomorrow.\n Rec initiating TPN for nutrition support to prevent further nutritional\n decline.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start w/ day 1 TPN: 1L(150gdex, 70g aa) w/ non-std lytes to\n provide 800kcals/day.\n 2. Adv to goal TPN as BG allow to 2L(320gdex, 100g AA, 40g lipid)\n to provide 1888kcals/day.\n 3. c/w lyte mngt as you are- noted low Phos today, replete prn.\n 4. Monitor hydration status.\n 5. Check trig w/ am labs, no lipid in TPN if >400\n Will f/u w/ progress/ transition to feeds.\n Please page w/ questions #\n 05:36 PM\n" }, { "category": "Nursing", "chartdate": "2199-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557611, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admission for pneumosepsis due to aspiration treated\n with IV vanco. Today, found with temp 103 oral, lethargic and\n hypotensive with sbp in 70s. Pt had recently completed course of oral\n vanco for c-diff. Started on fluids, levo, dopamine, and vasopressin\n in ED. s/p subtotal colectomy w ileostomy and taken back for bleeding\n \n patient returned to OR and had closure of abdominal wound and\n placement of GJ tube.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcers on right and left gluteral area. .\n Action:\n Turned q2hrs, mepiflex dsg renewed, pressure ulcers looked improved.\n Patient placed on special air mattress to prevent further breakdown of\n skin\n Response:\n pressure ulcers looked improved, no new breakdowns\n Plan:\n Continue to turn q2hrs. Confer with wound nurse\n Electrolyte & fluid disorder, other\n Assessment:\n labs checked Potassium and calcium low, sodium high 150\n Action:\n Iv potassium and calcium supplement given per sliding scale, patient to\n have free water, kvo changed to d5w. Patient also to have 25g albumin\n Q8 x 48 hrs.\n Response:\n Sodium slowly coming down, potassium needed further repletion.\n Plan:\n Will monitor electrolyte and replace as needed.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Patient Hr remains sr and blood pressure maintained with out any\n pressers at time of report. Labs monitored no change in hct. No signs\n of active bleeding, no distension noted.\n Action:\n Will continue to monitor vitals closely and girth for signs of\n bleeding. Monitor dressing for bleeding.\n Response:\n Hr and vitals stable at time of report,\n Plan:\n Monitor patient closely for hypovolemia and bleeding.\n IV propofol used for light sedation, patient complaining of a lot of\n abdominal and leg pain (this is not a new issue patient has chronic leg\n pain. IV fentanyl gtt started to keep patient comfortable.\n Family updated on patient\ns condition.\n Patient placed on cpap, tolerating at time of report, abg monitored and\n reviewed by team, continue on current settings.\n Patient to start tube feeds and free water flushes, will monitor\n residuals closely\n" }, { "category": "Nursing", "chartdate": "2199-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558074, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP, tolerating well.\n Action:\n Pt extubated at 09:30\n Response:\n Pt required chest PT and regular suctioning to maintain airway\n initially, now more stable, able to maintain airway himself.\n Plan:\n Encourage C+DB\n" }, { "category": "General", "chartdate": "2199-02-08 00:00:00.000", "description": "Generic Note", "row_id": 558253, "text": "TITLE: Attempted Bedside Swallow Evaluation\n I attempted to complete the bedside swallow evaluation, but pt refused\n PO pain. He should remain NPO with continued tube feeds and we will\n f/u Monday. Please see Web OMR or paper chart for additional details.\n , MS, CCC-SLP\n Pager#\n 13:56\n" }, { "category": "Respiratory ", "chartdate": "2199-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557536, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\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: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\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:\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 Reason for continuing current ventilatory support:\n" }, { "category": "Nursing", "chartdate": "2199-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557929, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt potassium level 3.4 from 1700, mag level 1.7 at 1700. Pt continues\n to be positive from LOS cumulative\n Action:\n Pt repleted electrolytes as per orders\n Response:\n Electrolytes improved after repletion. Pt continued to autodiurese\n approximately 200cc or more an hour\n Plan:\n Follow labs, replete PRN. Follow I/Os with goal to keep negative\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated, pox 98-100%. LS clear but diminished at bases\n Action:\n ABGs monitored\n Response:\n Pt\ns vent settings changed to CPAP 5 peep, 10PS\n Plan:\n Continue to follow ABGs, pox and respiratory assessments. Wean settings\n as tolerated with goal to extubate when pt is able\n" }, { "category": "Physician ", "chartdate": "2199-02-08 00:00:00.000", "description": "Intensivist Note", "row_id": 558323, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 09:33 AM\n INVASIVE VENTILATION - STOP 09:34 AM\n morphine started but pain still remains an issue, extubated, self\n diuresing 2.6L yesterday\n Post operative day:\n POD#7 - Subtotal colectomy\n POD#7 - exp lap and oversewing of messenteric vessel.\n POD#4 - exploratory laparotomy abdominal washout and closure\n placement of GJ tube.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:02 PM\n Vancomycin - 02:19 AM\n Metronidazole - 04:11 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:45 PM\n Hydralazine - 09:15 PM\n Heparin Sodium (Prophylaxis) - 04:11 AM\n Metoprolol - 04:11 AM\n Famotidine (Pepcid) - 07:57 AM\n Other medications:\n Flowsheet Data as of 09:05 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: 36.7\nC (98\n HR: 100 (80 - 111) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 15 (9 - 27) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 77.3 kg (admission): 70 kg\n Height: 66 Inch\n CVP: 13 (0 - 13) mmHg\n Total In:\n 2,953 mL\n 1,313 mL\n PO:\n Tube feeding:\n 1,441 mL\n 630 mL\n IV Fluid:\n 1,252 mL\n 263 mL\n Blood products:\n 100 mL\n Total out:\n 5,635 mL\n 1,500 mL\n Urine:\n 5,385 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,682 mL\n -187 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SPO2: 96%\n ABG: 7.39/55/196/31/7\n PaO2 / FiO2: 490\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), shovel mask in place\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: erythema at base of abdominal wound\n Neurologic: Follows simple commands,\n Labs / Radiology\n 354 K/uL\n 10.2 g/dL\n 186 mg/dL\n 0.3 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 4 mg/dL\n 102 mEq/L\n 141 mEq/L\n 30.1 %\n 21.3 K/uL\n [image002.jpg]\n 08:26 AM\n 11:08 AM\n 05:19 PM\n 02:20 AM\n 02:35 AM\n 08:30 AM\n 10:59 AM\n 12:09 PM\n 04:26 PM\n 04:43 AM\n WBC\n 15.4\n 21.3\n Hct\n 26.2\n 30.1\n Plt\n 219\n 354\n Creatinine\n 0.4\n 0.4\n 0.3\n 0.3\n TCO2\n 30\n 30\n 32\n 33\n 32\n 35\n Glucose\n 74\n 84\n 93\n 112\n 186\n Other labs: PT / PTT / INR:14.7/36.5/1.3, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:82/31, Alk-Phos / T bili:43/0.8, Amylase /\n Lipase:74/44, Fibrinogen:392 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.0\n g/dL, LDH:203 IU/L, Ca:8.1 mg/dL, Mg:2.0 mg/dL, PO4:1.2 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: fentanyl gtt. Started morphine 15Q4h, restart home\n neurontin\n Cardiovascular: lop 15Q4h; hydral prn\n Pulmonary: Extubated; pulmonary toilet\n GI: s/p abdominal closure, follow erythema around wound; abdomen soft\n Nutrition: tube feeds advanced to goal\n Renal: KVO; diuresed without lasix, 2.6 L neg yesterday; Na 141 so will\n decrease free water replacement; continue albumin one more day \n today\n Hematology: stable\n Endocrine: SSI\n Infectious Disease: leukocytosis, low grade temp, cdiff, IV flagyl. PO\n Vanco started . zosyn d/ced .\n Lines/Tubes/Drains: foley, R IJ, aline\n Wounds: open to air with mild erythema\n Imaging: none\n Fluids: KVO\n Prophylaxis: boots, hep sq, h2b\n Consults: General Surgery\n Disposition: SICU\n Consults: general surgery\n Billing Diagnosis: Resp Failure; Post-op complication\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:41 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557351, "text": ".H/O acidosis, Metabolic\n Assessment:\n On fentanyl and versed gtt. Abd open with drain present. Does not move\n right arm or leg. moves left arm off the bed does not move left leg.\n opens eyes to loud stimuli . nods head to questions\n Action:\n Fentanyl and versed gtt. Abd open with jp drain to lcws. Labs prn.\n Lasix 20mgivp x1. good diuresis. Remains vented. On pipercillin and\n flagyl iv.\n Response:\n Stable post op\n Plan:\n To or today\n" }, { "category": "Physician ", "chartdate": "2199-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 557366, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1000 mL LR 5. Calcium Gluconate 6. Chlorhexidine Gluconate 0.12% Oral\n Rinse 7. Famotidine\n 8. Fentanyl Citrate 9. Furosemide 10. Furosemide 11. HYDROmorphone\n (Dilaudid) 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. Hydrocortisone Na Succ. 15. Insulin 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Norepinephrine 20. Piperacillin-Tazobactam Na 21. Potassium\n Chloride 22. Sodium Chloride 0.9% Flush\n 23. Sodium Chloride 0.9% Flush 24. Vancomycin Enema\n 24 Hour Events:\n EKG - At 09:55 AM\n Post operative day:\n POD#3 - Subtotal colectomy\n POD#3 - exp lap and oversewing of messenteric vessel.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Metronidazole - 06:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:58 AM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:16 AM\n Famotidine (Pepcid) - 06:00 PM\n Furosemide (Lasix) - 10:17 PM\n Other medications:\n Flowsheet Data as of 03:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.4\n T current: 36.3\nC (97.4\n HR: 74 (67 - 83) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (0 - 17) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 5 (3 - 13) mmHg\n Total In:\n 3,261 mL\n 216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,261 mL\n 216 mL\n Blood products:\n Total out:\n 3,535 mL\n 400 mL\n Urine:\n 2,000 mL\n 200 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 1,250 mL\n 200 mL\n Balance:\n -274 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (0 - 600) mL\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 31\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 42.9 cmH2O/mL\n SPO2: 100%\n ABG: 7.43/39/130/25/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Abd open\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 9.9 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 116 mEq/L\n 148 mEq/L\n 27.7 %\n 10.8 K/uL\n [image002.jpg]\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n 04:10 AM\n 04:22 AM\n 09:35 AM\n 06:04 PM\n 06:21 PM\n WBC\n 7.4\n 10.1\n 9.6\n 10.9\n 10.8\n Hct\n 28.1\n 26.3\n 27.0\n 26.7\n 27.7\n Plt\n 96\n 96\n 80\n 95\n 86\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 24\n 27\n 29\n 27\n 27\n Glucose\n 93\n 79\n 87\n 84\n 80\n Other labs: PT / PTT / INR:20.0/37.2/1.9, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:289/198, Alk-Phos / T bili:30/1.4,\n Fibrinogen:159 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:1.3 g/dL, LDH:188\n IU/L, Ca:7.3 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip; moves LUE\n Cardiovascular: HD stable over night, MAP>60 as goal.\n Pulmonary: : wean vent as tolerated\n Gastrointestinal / Abdomen: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: Foley, Rd lasix 40mg (is on lasix at home)\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: cdiff, Started on flagyl/zosyn. vanc enemas\n Lines / Tubes / Drains: : foley, femoral line, R IJ, aline, JP\n Wounds: open abd wound\n Imaging: None\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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": "Physician ", "chartdate": "2199-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 556944, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n cdiff colitis\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1456\n 17. Heparin Flush (10 units/ml) 1 mL IV PRN line flush\n Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed\n by Heparin as above daily and PRN. Order date: @ 1456\n 2. IV access: Temporary central access (Floor) Location: Right Femoral,\n Date inserted: Order date: @ 1456 18. Hespan 500 mL IV\n ONCE Duration: 1 Doses Order date: @ 1456\n 3. IV access: Peripheral line Order date: @ 1456 19.\n Hydrocortisone Na Succ. 100 mg IV Q8H Order date: @ 1456\n 4. 1000 mL LR\n Continuous at 200 ml/hr Order date: @ 1456 20. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1456\n 5. 1000 mL LR Bolus 1000 ml Over 30 mins Order date: @ 1456 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1456\n 6. 1000 mL NS Bolus 5000 ml Over 60 mins Order date: @ 1456 22.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1456\n 7. 1000 mL LR Bolus ml Over 60 mins Order date: @ 1456 23.\n Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO comfort\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0411\n 8. 1000 mL LR Bolus 1000 ml Over 60 mins Order date: @ 2118 24.\n Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP INFUSION Order date: \n @ 1456\n 9. 1000 mL LR Bolus 1000 ml Over 30 mins Order date: @ 0037 25.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 Order date:\n @ 1456\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 1456 26.\n Piperacillin-Tazobactam Na 4.5 gm IV ONCE Duration: 1 Doses Order date:\n @ 1456\n 11. Calcium Chloride 1 gm IV ONCE Duration: 1 Doses Order date: @\n 1456 27. Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @\n 1456\n 12. Calcium Chloride 1 gm IV ONCE Duration: 1 Doses Order date: @\n 1456 28. Potassium Chloride IV Sliding Scale Order date: @ 1456\n 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1810 29. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1456\n 14. Fentanyl Citrate 25-300 mcg/hr IV DRIP INFUSION Order date: \n @ 0037 30. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1456\n 15. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN Order date: \n @ 1456 31. Vasopressin 1.2 UNIT/HR IV DRIP TITRATE TO MAP > 60 Order\n date: @ 1456\n 16. Heparin 5000 UNIT SC TID Order date: @ 1456 32. Vancomycin\n Enema 100 mg PR QID\n hold Order date: @ 2230\n 24 Hour Events:\n OR RECEIVED - At 09:46 AM\n MULTI LUMEN - START 01:00 PM\n : s/p subtotal colectomy and then take back for rebleeding\n Post operative day:\n POD#1 - Subtotal colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Metronidazole - 02:09 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 12:41 PM\n Fentanyl - 12:33 AM\n Other medications:\n Flowsheet Data as of 04:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 93 (72 - 122) bpm\n BP: 133/53(66) {62/23(35) - 133/75(79)} mmHg\n RR: 13 (12 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 282 (11 - 287) mmHg\n Total In:\n 33,714 mL\n 2,333 mL\n PO:\n Tube feeding:\n IV Fluid:\n 19,933 mL\n 2,333 mL\n Blood products:\n 6,781 mL\n Total out:\n 6,090 mL\n 1,010 mL\n Urine:\n 1,810 mL\n 210 mL\n NG:\n 400 mL\n 100 mL\n Stool:\n Drains:\n 1,600 mL\n 700 mL\n Balance:\n 27,624 mL\n 1,323 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 514 (514 - 514) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 42.9 cmH2O/mL\n SPO2: 100%\n ABG: 7.38/21/215/21/-10\n Ve: 10.5 L/min\n PaO2 / FiO2: 537\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, abdomen open, JP serosang\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 Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 97 K/uL\n 12.7 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 118 mEq/L\n 146 mEq/L\n 32.5 %\n 7.6 K/uL\n [image002.jpg]\n 01:14 PM\n 01:51 PM\n 02:10 PM\n 03:00 PM\n 03:20 PM\n 05:29 PM\n 06:51 PM\n 09:49 PM\n 01:08 AM\n 03:09 AM\n WBC\n 5.5\n 5.8\n 7.6\n Hct\n 8\n 15\n 23\n 39.6\n 33.7\n 32.9\n 32.5\n Plt\n 49\n 91\n 88\n 97\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n Troponin T\n 0.08\n TCO2\n 10\n 8\n 15\n 14\n 15\n 13\n Glucose\n 221\n 294\n 213\n 166\n 147\n Other labs: PT / PTT / INR:20.1/42.0/1.9, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:628/750, Alk-Phos / T bili:27/0.5,\n Fibrinogen:159 mg/dL, Lactic Acid:3.3 mmol/L, Albumin:1.3 g/dL,\n LDH:1400 IU/L, Ca:8.3 mg/dL, Mg:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n .H/O ACIDOSIS, METABOLIC, ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK,\n HYPOVOLEMIC OR HEMORRHAGIC, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE,\n ARF), AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip\n Cardiovascular: HD improving over night, MAP>60 as goal. Cont\n aggressive resuscitation On norepi gtt, neo gtt, and vasopressin -\n weaning as tolerated (almost off at this point)\n Pulmonary: Intubated, wean vent as tolerated\n Gastrointestinal / Abdomen: NPO. f/u JP output, abdomen open - will\n need return to OR - ? Monday\n Nutrition: NPO\n Renal: monitor uop - adequate at this point, f/u creat\n Hematology: f/u serial cbc and coags - transfuse as necessary, crits\n now stable\n Endocrine: RISS\n Infectious Disease: cdiff, Started on flagyl/zosyn\n Lines / Tubes / Drains: foley, femoral line, R IJ, aline, JP\n Wounds: open abd wound\n Imaging:\n Fluids: LR @ 200 ml/hr\n Consults: General Sugery\n Billing Diagnosis: Post-op hypotension, Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Multi Lumen - 01:00 PM\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:\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556993, "text": ".H/O acidosis, Metabolic\n Assessment:\n Does not move right arm or leg. Moves left arm off the bed but does not\n move left leg. Contracted hands and bilateral foot drop. Bp occ\n dropping to 90\ns levo gtt titrated.\n Action:\n Lactated ringers bolus x3 = 2500cc iv magnesium , iv calcium glucionate\n and iv kcl given as ordered. Levophed gtt titrated. Map > 60. iv\n lactated ringers at 200cc/hr. fentanyl and versed gtt added for\n comfort. Ngt to lcws. On iv flagyl and iv pipercilllin. Abd jp to wall\n suction labs prn update to family.\n Response:\n Remains in sinus rythmn, on fentanyl and versed gtt. Map > 60 levo\n being weaned. Stable nite.\n Plan:\n Monitor condition closely, attempt to wean levo gtt off. To or on mon\n for abdonmial closure. Notifiy family\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557063, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure Monday\n Wound care consult placed\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 5. ABG due at 1700\n Response:\n No change in pt status. Post ABG\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr.\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcer on pt right gluteal side. 7cmx4cm. Stage 2 on pt left\n gluteal side 3cmx3cm in size. Small skin tear on pt left upper thigh\n near gluteal fold. Stage one pressure ulcer vs full thickness breakdown\n on pt left upper thigh.\n Action:\n Pt turned Q2hr and prn. Mepilex foam dressing applied to ulcers. Sites\n cleaned and pat dry. Pt turned completely to each side. Wound care\n consult placed today. Order for step one mattress placed today.\n Response:\n No change in pt skin at this time.\n Plan:\n Follow up with wound consult on Monday. Place pt on new mattress\n tonight. Continue to turn pt Q2hr and prn. Make sure pt is off back\n completely. Dressing can stay in place for 3 days. Please change\n dressing on the 17^th.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557066, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure Monday\n Wound care consult placed\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 5. ABG due at 1700\n Response:\n No change in pt status. Post ABG 7.43/43/126/4/29\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr. Large output from JP drain today. Thin bloody drainage. MD\n aware of output. Total for this shift .\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt. Recheck CBC, lytes tonight.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcer on pt right gluteal side. 7cmx4cm. Stage 2 on pt left\n gluteal side 3cmx3cm in size. Small skin tear on pt left upper thigh\n near gluteal fold. Stage one pressure ulcer vs full thickness breakdown\n on pt left upper thigh.\n Action:\n Pt turned Q2hr and prn. Mepilex foam dressing applied to ulcers. Sites\n cleaned and pat dry. Pt turned completely to each side. Wound care\n consult placed today. Order for step one mattress placed today.\n Response:\n No change in pt skin at this time.\n Plan:\n Follow up with wound consult on Monday. Place pt on new mattress\n tonight. Continue to turn pt Q2hr and prn. Make sure pt is off back\n completely. Dressing can stay in place for 3 days. Please change\n dressing on the 17^th.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557069, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure Monday\n Wound care consult placed\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 5. ABG due at 1700\n Response:\n No change in pt status. Post ABG 7.43/43/126/4/29\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr. Large output from JP drain today. Thin bloody drainage. MD\n aware of output. Total for this shift 1150cc .\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt. Recheck CBC, lytes tonight.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcer on pt right gluteal side. 7cmx4cm. Stage 2 on pt left\n gluteal side 3cmx3cm in size. Small skin tear on pt left upper thigh\n near gluteal fold. Stage one pressure ulcer vs full thickness breakdown\n on pt left upper thigh.\n Action:\n Pt turned Q2hr and prn. Mepilex foam dressing applied to ulcers. Sites\n cleaned and pat dry. Pt turned completely to each side. Wound care\n consult placed today. Order for step one mattress placed today.\n Response:\n No change in pt skin at this time.\n Plan:\n Follow up with wound consult on Monday. Place pt on new mattress\n tonight. Continue to turn pt Q2hr and prn. Make sure pt is off back\n completely. Dressing can stay in place for 3 days. Please change\n dressing on the 17^th.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557219, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\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: 25 cm at teeth\n Route: Oral\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: ett advanced 1cm MD .\n Lung sounds\n RLL Lung Sounds: Rhonchi\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 / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: periods of apnea on CPAP. back on a/c w/ gd effect.\n Assessment of breathing comfort: No response (sleeping / sedated)\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: Adjust Min. ventilation to control pH; Comments: plan\n to diurese MD.\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 Comments:\n 15:21\n" }, { "category": "Nursing", "chartdate": "2199-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557423, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admission for pneumosepsis due to aspiration treated\n with IV vanco. Today, found with temp 103 oral, lethargic and\n hypotensive with sbp in 70s. Pt had recently completed course of oral\n vanco for c-diff. Started on fluids, levo, dopamine, and vasopressin\n in ED. s/p subtotal colectomy w ileostomy and taken back for bleeding\n \n patient returned to OR and had closure of abdominal wound and\n placement of GJ tube.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcers on right and left gluteral area. .\n Action:\n Turned q2hrs, mepiflex dsg renewed, pressure ulcers looked improved.\n Patient placed on special air mattress to prevent further breakdown of\n skin\n Response:\n pressure ulcers looked improved, no new breakdowns\n Plan:\n Continue to turn q2hrs, dsg to remain intact for 3days. Confer with\n wound nurse\n Electrolyte & fluid disorder, other\n Assessment:\n On return from OR patient labs checked Potassium and calcium low\n Action:\n Iv potassium and calcium supplement given per sliding scale\n Response:\n Will recheck labs at 18pm waiting results.\n Plan:\n Will monitor electrolyte and replace as needed.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Patient Hr remains sr and blood pressure maintained with out any\n pressers at time of report. Labs monitored no change in hct. No signs\n of active bleeding, no distension noted.\n Action:\n Will continue to monitor vitals closely and girth for signs of\n bleeding. Monitor dressing for bleeding.\n Response:\n Hr and vitals stable at time of report,\n Plan:\n Monitor patient closely for hypovolemia and bleeding.\n IV propofol used for light sedation, IV fentanyl prn for pain control.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 556969, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\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 weaned per ABG\nS.Agitated at times,biting on ETT. Placed\n on PCV for a short time. Sedated with fentanyl and midazolam. Now back\n on A/C.Temp 99.8.Will cont to monitor resp status.\n" }, { "category": "Physician ", "chartdate": "2199-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 556817, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED.\n Chief complaint:\n abdominal pain\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. 1000 mL LR 3. HYDROmorphone (Dilaudid) 4. Heparin 5. Insulin 6.\n MetRONIDAZOLE (FLagyl) 7. Norepinephrine\n 8. Phenylephrine 9. Sodium Chloride 0.9% Flush 10. Vasopressin\n 24 Hour Events:\n ARTERIAL LINE - START 02:13 AM\n MULTI LUMEN - START 02:14 AM\n BLOOD CULTURED - At 02:28 AM\n OR SENT - At 04:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 74 (74 - 101) bpm\n BP: 125/68(88) {122/68(87) - 146/79(104)} mmHg\n RR: 20 (12 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n Blood products:\n 274 mL\n Total out:\n 0 mL\n 1,030 mL\n Urine:\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,525 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.29/35/90./19/-8\n Physical Examination\n (At admission prior to OR)\n NAD, aphasic, drowsy\n RRR\n Rhonchi on lung exam\n Abd soft, NT but signicantly distended\n No edema\n Labs / Radiology\n 278 K/uL\n 9.6 g/dL\n 186 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 19 mg/dL\n 115 mEq/L\n 139 mEq/L\n 30.0 %\n 11.5 K/uL\n [image002.jpg]\n 02:13 AM\n 02:20 AM\n 02:52 AM\n 05:15 AM\n 06:23 AM\n 07:18 AM\n 07:50 AM\n WBC\n 25.8\n 11.5\n Hct\n 35.6\n 33\n 33\n 31\n 30.0\n Plt\n 371\n 278\n Creatinine\n 0.7\n TCO2\n 21\n 19\n 18\n 18\n 18\n Glucose\n 397\n 277\n 229\n 186\n Other labs: PT / PTT / INR:24.0/38.4/2.3, Fibrinogen:401 mg/dL, Lactic\n Acid:3.4 mmol/L, Ca:6.4 mg/dL, Mg:1.7 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis\n Neurologic: This is a 62 yo M with PMH of HTN, type 2 DM, embolic and\n hemorrhagic CVA, and history of DVT who presents with sepsis likely\n secondary to c. diff colitis\n Cardiovascular: MAP>60. On norepi gtt and neo gtt\n Pulmonary: keep sao2 above 92% on 4l nc\n Gastrointestinal / Abdomen: NPO. Plan to OR for colectomy this am\n Nutrition: NPO\n Renal: monitor uop\n Hematology: crit stable, 1 unit ffp\n Endocrine: SSI\n Infectious Disease: cultures pending. Started on flagyl.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 02:14 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2199-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 556909, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\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: No\n Procedure location: OR\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\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: 8 mL / Air\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: Clear / 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 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:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved; Comments: pt\n brought to ICU from OR intubated today and returned shortly after for\n repair of bleed, to remain intubated through PM shift, plan to be\n revaluated in AM. PT on 15 of PEEP.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2199-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 556807, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED.\n Chief complaint:\n abdominal pain\n PMHx:\n Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic left\n thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n Current medications:\n 1. 2. 1000 mL LR 3. HYDROmorphone (Dilaudid) 4. Heparin 5. Insulin 6.\n MetRONIDAZOLE (FLagyl) 7. Norepinephrine\n 8. Phenylephrine 9. Sodium Chloride 0.9% Flush 10. Vasopressin\n 24 Hour Events:\n ARTERIAL LINE - START 02:13 AM\n MULTI LUMEN - START 02:14 AM\n BLOOD CULTURED - At 02:28 AM\n OR SENT - At 04:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 74 (74 - 101) bpm\n BP: 125/68(88) {122/68(87) - 146/79(104)} mmHg\n RR: 20 (12 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,281 mL\n Blood products:\n 274 mL\n Total out:\n 0 mL\n 1,030 mL\n Urine:\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7,525 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.29/35/90./19/-8\n Physical Examination\n (At admission prior to OR)\n NAD, aphasic, drowsy\n RRR\n Rhonchi on lung exam\n Abd soft, NT but signicantly distended\n No edema\n Labs / Radiology\n 278 K/uL\n 9.6 g/dL\n 186 mg/dL\n 0.7 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 19 mg/dL\n 115 mEq/L\n 139 mEq/L\n 30.0 %\n 11.5 K/uL\n [image002.jpg]\n 02:13 AM\n 02:20 AM\n 02:52 AM\n 05:15 AM\n 06:23 AM\n 07:18 AM\n 07:50 AM\n WBC\n 25.8\n 11.5\n Hct\n 35.6\n 33\n 33\n 31\n 30.0\n Plt\n 371\n 278\n Creatinine\n 0.7\n TCO2\n 21\n 19\n 18\n 18\n 18\n Glucose\n 397\n 277\n 229\n 186\n Other labs: PT / PTT / INR:24.0/38.4/2.3, Fibrinogen:401 mg/dL, Lactic\n Acid:3.4 mmol/L, Ca:6.4 mg/dL, Mg:1.7 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis\n Neurologic: This is a 62 yo M with PMH of HTN, type 2 DM, embolic and\n hemorrhagic CVA, and history of DVT who presents with sepsis likely\n secondary to c. diff colitis\n Cardiovascular: MAP>60. On norepi gtt and neo gtt\n Pulmonary: keep sao2 above 92% on 4l nc\n Gastrointestinal / Abdomen: NPO. Plan to OR for colectomy this am\n Nutrition: NPO\n Renal: monitor uop\n Hematology: crit stable, 1 unit ffp\n Endocrine: SSI\n Infectious Disease: cultures pending. Started on flagyl.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds:\n Imaging:\n Fluids:\n Consults: General surgery\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n Multi Lumen - 02:14 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 557106, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Chief complaint:\n PMHx:\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. 1000 mL LR 6. Calcium Gluconate 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Famotidine 9. Fentanyl Citrate 10. HYDROmorphone (Dilaudid) 11.\n Heparin 12. Heparin Flush (10 units/ml)\n 13. Hydrocortisone Na Succ. 14. Insulin 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midazolam\n 18. Norepinephrine 19. Piperacillin-Tazobactam Na 20. Potassium\n Chloride 21. Sodium Chloride 0.9% Flush\n 22. Sodium Chloride 0.9% Flush 23. Vancomycin Enema\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:00 AM\n OR RECEIVED - At 09:46 AM\n MULTI LUMEN - START 01:00 PM\n Received FFP, off pressors\n Post operative day:\n POD#2 - Subtotal colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Metronidazole - 02:21 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 05:46 PM\n Heparin Sodium (Prophylaxis) - 10:50 PM\n Other medications:\n Flowsheet Data as of 03:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.9\nC (98.5\n HR: 75 (75 - 96) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 0 (0 - 18) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 8 (5 - 16) mmHg\n Total In:\n 7,539 mL\n 723 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,995 mL\n 723 mL\n Blood products:\n 544 mL\n Total out:\n 2,990 mL\n 315 mL\n Urine:\n 810 mL\n 115 mL\n NG:\n 100 mL\n Stool:\n Drains:\n 2,050 mL\n 200 mL\n Balance:\n 4,549 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 514 (514 - 514) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n Compliance: 40 cmH2O/mL\n SPO2: 99%\n ABG: 7.43/43/126/27/4\n Ve: 7.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 96 K/uL\n 9.8 g/dL\n 79 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 118 mEq/L\n 148 mEq/L\n 26.3 %\n 10.1 K/uL\n [image002.jpg]\n 06:51 PM\n 09:49 PM\n 01:08 AM\n 03:09 AM\n 05:33 AM\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n WBC\n 5.8\n 7.6\n 7.4\n 10.1\n Hct\n 32.9\n 32.5\n 28.1\n 26.3\n Plt\n 88\n 97\n 96\n 96\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 15\n 13\n 20\n 24\n 27\n 29\n Glucose\n 166\n 147\n 93\n 79\n Other labs: PT / PTT / INR:19.7/40.2/1.8, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:628/750, Alk-Phos / T bili:27/0.5,\n Fibrinogen:159 mg/dL, Lactic Acid:2.3 mmol/L, Albumin:1.3 g/dL,\n LDH:1400 IU/L, Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip\n Cardiovascular: HD stable over night, MAP>60 as goal. Cont\n resuscitation, off pressors\n Pulmonary: Intubated, wean vent as tolerated\n Gastrointestinal/Abdominal: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: monitor uop\n Hematology: f/u serial cbc and coags, HCT slowing drifting down,\n maintains dilute blood tinged output via abd drains\n Endocrine: SSI\n Infectious Disease: cdiff, Started on flagyl/zosyn.\n Lines/Tubes/Drains: foley, femoral line, R IJ, aline, JP.\n Wounds: open abd wound\n Imaging: none\n Fluids: LR @ 100 ml/hr\n Prophylaxis: boots, hep sq, h2b\n Consults: General Sugery\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n 20 Gauge - 02:15 AM\n Multi Lumen - 01:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2199-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557459, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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: 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: 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 Patient S/Pcolectomy went to OR today for abdominal closure.Remains on\n mechanical ventilation.Suctioned for scant to no secretion.mini CVA in\n the past,quadriplegic will continue to follow.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557040, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 6. ABG due at 1700\n Response:\n No change in pt status.\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr.\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557041, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Held a Family meeting today with Dr. .\n Plan for closure monday\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 40%. Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN. PCXR done at 1600. Vent settings changed to RR of 12 and Peep\n 6. ABG due at 1700\n Response:\n No change in pt status.\n Plan:\n Continue oral care. Plan for CXR in am. Continue to wean vent as\n tolerated.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n . K 3.5. Replaced with 40meq KCL per SS. IV fluids changed to\n 100cc/hr.\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 100cc/hr.\n Plan:\n Continue to monitor pt.\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557031, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 . Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN.\n Response:\n No change in pt status.\n Plan:\n Continue oral care. Plan for CXR in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557035, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 . Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN.\n Response:\n No change in pt status.\n Plan:\n Continue oral care. Plan for CXR in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. Pt given 500 cc fluid bolus of LR.\n Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500. CO range: 4.6-5.8, CI: 2.6-3.2, SV: 52-69, CVP:\n .\n Response:\n Levo off at 1100. Pt map 70 or greater at this time. Continue IV fluids\n at 200cc/hr.\n Plan:\n Continue to monitor pt.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557085, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: 24 cm at teeth\n Route: Oral\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: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\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 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: Adjust Min. ventilation to control pH\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 Comments:\n 19:14\n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557032, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CMV with Peep 8, Rate 14, Fio2 . Thick yellow\n secretions suctioned. Lots of oral secretions noted. Pt high risk for\n aspiration. Impaired gag reflex. Lungs diminished in the bases.\n Action:\n ABG done at 7am and again at 1500. Pt suctioned Q2-3 hr. Oral care Q4hr\n and PRN.\n Response:\n No change in pt status.\n Plan:\n Continue oral care. Plan for CXR in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Pt on Levo at 0.15mcg/kg/min. Goal for map 60 or greater. IV fluids at\n 200cc/hr. Hr 80-90\ns SR. No ectopy. CO CI. Pt given 500 cc fluid bolus\n of LR. Pt on fentanyl drip and versed for pain and sedation.\n Action:\n Pt given plasma as ordered. Tolerated well. Wean down levo per policy.\n Labs sent at 1500.\n Response:\n Levo off at . Pt map 70 or greater at this time. Continue iv fluids at\n 200cc/hr.\n Plan:\n Continue to monitor pt.\n" }, { "category": "Respiratory ", "chartdate": "2199-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 557303, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\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: White / Thick\n Sputum source/amount: Suctioned / Small\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 remains on current vent settings. See vent flow sheet for\n details.Sedated with fentanyl and midazolam. To OR today to close\n belly. No RSBI done. Will cont to monitor resp status.\n" }, { "category": "Nursing", "chartdate": "2199-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557230, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n" }, { "category": "Nursing", "chartdate": "2199-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557023, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\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 Shock, hypovolemic or hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557231, "text": "62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcer on right and left gluteral area. Skin tear on coccyx.\n Action:\n Turned q2hrs, mepiflex dsg intact. Patient placed on special air\n mattress to prevent further breakdown of skin\n Response:\n No change with dsg on coccyx intact.\n Plan:\n Continue to turn q2hrs, dsg to remain intact for 3days . Confer with\n wound nurse\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Levophed gtt remains off wilth bpmean > 60. hct 26. plts80. comfortable\n on iv fentanyl and versed gtts/ for pain control and comfort.\n Action:\n Lactated ringers at kvo. Iv fentanyl and versed infusing, titrated for\n comfort. Suction prn. Cardiac output/ index and svr via vigelleo. Labs\n prn. Remains vented and abg done. Abd remains open with jp drain to\n suction see icu flow sheet for shift total.\n Response:\n Stable post op\n Plan:\n Monitor condition closely to or on Monday for abd closure.\n" }, { "category": "Physician ", "chartdate": "2199-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 557291, "text": "SICU\n HPI:\n 62 yo Spanish speaking M with PMH of HTN, DM, embolic and hemorrhagic\n CVA, aphasia, DVT who presents with hypotension and lethargy. Pt had\n recent admision for pneumosepsis due to aspiration treated with\n IV vanco. Today, found with temp 103 oral, lethargic and hypotensive\n with sbp in 70s. Pt had recently completed course of oral vanco for\n c-diff. Started on fluids, levo, dopamine, and vasopressin in ED. s/p\n subtotal colectomy w ileostomy and takeback for bleeding \n Chief complaint:\n PMHx:\n PMH:-Hypertension,CVA: bilateral embolic cerebellar , hemorrhagic\n left thalamic , Type II Diabetes mellitus, Peripheral neuropathy ,\n Constipation, Dysphagia, Depression, Hypothyroidism h/o DVT\n PSH:s/p lap chole at , s/p INH as child, Hip surgery\n Current medications:\n 1000 mL LR 5. Calcium Gluconate 6. Chlorhexidine Gluconate 0.12% Oral\n Rinse 7. Famotidine\n 8. Fentanyl Citrate 9. Furosemide 10. Furosemide 11. HYDROmorphone\n (Dilaudid) 12. Heparin 13. Heparin Flush (10 units/ml)\n 14. Hydrocortisone Na Succ. 15. Insulin 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Midazolam\n 19. Norepinephrine 20. Piperacillin-Tazobactam Na 21. Potassium\n Chloride 22. Sodium Chloride 0.9% Flush\n 23. Sodium Chloride 0.9% Flush 24. Vancomycin Enema\n 24 Hour Events:\n EKG - At 09:55 AM\n Post operative day:\n POD#3 - Subtotal colectomy\n POD#3 - exp lap and oversewing of messenteric vessel.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Piperacillin - 12:47 AM\n Metronidazole - 06:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:58 AM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:16 AM\n Famotidine (Pepcid) - 06:00 PM\n Furosemide (Lasix) - 10:17 PM\n Other medications:\n Flowsheet Data as of 03:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.3\nC (97.4\n T current: 36.3\nC (97.4\n HR: 74 (67 - 83) bpm\n BP: 133/53(66) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (0 - 17) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 5 (3 - 13) mmHg\n Total In:\n 3,261 mL\n 216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,261 mL\n 216 mL\n Blood products:\n Total out:\n 3,535 mL\n 400 mL\n Urine:\n 2,000 mL\n 200 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 1,250 mL\n 200 mL\n Balance:\n -274 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (0 - 600) mL\n Vt (Spontaneous): 730 (730 - 730) mL\n PS : 0 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 31\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 42.9 cmH2O/mL\n SPO2: 100%\n ABG: 7.43/39/130/25/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Abd open\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 86 K/uL\n 9.9 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 116 mEq/L\n 148 mEq/L\n 27.7 %\n 10.8 K/uL\n [image002.jpg]\n 07:41 AM\n 02:13 PM\n 02:24 PM\n 05:33 PM\n 10:07 PM\n 04:10 AM\n 04:22 AM\n 09:35 AM\n 06:04 PM\n 06:21 PM\n WBC\n 7.4\n 10.1\n 9.6\n 10.9\n 10.8\n Hct\n 28.1\n 26.3\n 27.0\n 26.7\n 27.7\n Plt\n 96\n 96\n 80\n 95\n 86\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n TCO2\n 24\n 27\n 29\n 27\n 27\n Glucose\n 93\n 79\n 87\n 84\n 80\n Other labs: PT / PTT / INR:20.0/37.2/1.9, CK / CK-MB / Troponin\n T:177/4/0.08, ALT / AST:289/198, Alk-Phos / T bili:30/1.4,\n Fibrinogen:159 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:1.3 g/dL, LDH:188\n IU/L, Ca:7.3 mg/dL, Mg:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION), .H/O ACIDOSIS, METABOLIC,\n ELECTROLYTE & FLUID DISORDER, OTHER, SHOCK, HYPOVOLEMIC OR HEMORRHAGIC,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), AIRWAY, INABILITY TO\n PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: This is a 62 yo M with PMH of HTN, type 2 DM,\n embolic and hemorrhagic CVA, and history of DVT who presents with\n sepsis likely secondary to c. diff colitis, s/p subtotal colectomy and\n take back for bleed\n Neurologic: Fentanyl drip, midaz drip; moves LUE\n Cardiovascular: HD stable over night, MAP>60 as goal.\n Pulmonary: : wean vent as tolerated\n Gastrointestinal / Abdomen: NPO. f/u JP output, abdomen open - will\n need return to OR Monday\n Nutrition: NPO\n Renal: Foley, Rd lasix 40mg (is on lasix at home)\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: cdiff, Started on flagyl/zosyn. vanc enemas\n Lines / Tubes / Drains: : foley, femoral line, R IJ, aline, JP\n Wounds: open abd wound\n Imaging: None\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:13 AM\n 18 Gauge - 02:14 AM\n Multi Lumen - 01:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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": "Nursing", "chartdate": "2199-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557484, "text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Stage 2 ulcers on right and left gluteral area. .\n Action:\n Patient placed on first step mattress to prevent further breakdown of\n skin\n Response:\n Pressure ulcers looked improved, no new breakdown\n Plan:\n Continue to turn q2hrs, dsg to remain intact for 3days. Confer with\n wound nurse\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Patient Hr remains sr and blood pressure maintained with out any\n pressers. No signs of active bleeding, no distension noted.\n Action:\n Will continue to monitor vitals closely and girth for signs of\n bleeding. Monitor dressing for bleeding.\n Response:\n Hr and vitals stable at time of report,\n Plan:\n Monitor patient closely for hypovolemia and bleeding\n For further details see metavision\n" }, { "category": "Radiology", "chartdate": "2199-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1064111, "text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with increased secretions\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:03 A.M., \n\n HISTORY: Increasing secretions, question aspiration.\n\n IMPRESSION: AP chest compared to through 21:\n\n Moderate to large bilateral pleural effusions, left greater than right,\n continue to increase. Left basal atelectasis is worsened. Although no\n consolidation is seen to suggest pneumonia, it could be missed given the\n extent of pleural abnormality. Cardiac silhouette is obscured. Mediastinal\n widening in the region of the great vessels is due to a generally tortuous\n aorta, but mostly dilated mediastinal veins. Right jugular line ends\n centrally. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062474, "text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension.\n\n CHEST, ONE VIEW: Comparison made to . Allowing for portable supine\n technique, cardiomediastinal contours are unchanged. Pulmonary vessels are\n not enlarged. Right mid lung linear opacity most likely represents fluid\n tracking in the minor fissure. Lungs are otherwise clear. There is no\n pneumothorax. Surgical clips in the right upper abdomen are stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063462, "text": " 3:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p thoracentesis, please eval for PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with\n REASON FOR THIS EXAMINATION:\n s/p thoracentesis, please eval for PTX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPSc WED 6:06 PM\n PFI: No definite pneumothorax on semi-upright x-ray. Possible slight\n decrease left pleural effusion. Question increase right upper lobe pulmonary\n edema.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Thoracentesis performed. Assess for pneumothorax.\n\n STUDY: Portable semi-upright frontal chest x-ray at 15:10.\n\n FINDINGS:\n\n Compared to 5:48 on , there is slightly less left thoracic density,\n consistent with smaller pleural effusion. No definite pneumothorax on this\n semi-upright x-ray. There is persistent atelectasis of much in the left lung.\n There is increased right perihilar and upper lung airspace opacity, likely\n reflecting pulmonary edema. Moderate right pleural effusion is unchanged as\n is right basilar atelectasis. NG tube has been removed, but the endotracheal\n tube and right jugular central venous catheter are in the expected and\n unaltered positions.\n\n IMPRESSION:\n No definite pneumothorax with slight decrease in left pleural effusion. New\n right upper lung and perihilar pulmonary edema with persistent bilateral\n moderate pleural effusions and atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063463, "text": ", S. SICU-A 3:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p thoracentesis, please eval for PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with\n REASON FOR THIS EXAMINATION:\n s/p thoracentesis, please eval for PTX\n ______________________________________________________________________________\n PFI REPORT\n PFI: No definite pneumothorax on semi-upright x-ray. Possible slight\n decrease left pleural effusion. Question increase right upper lobe pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2199-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063756, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypoxia after extubation\n REASON FOR THIS EXAMINATION:\n assess for PNA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 11:40 AM\n Improved aeration of the upper lobes. Large bilateral pleural effusions are\n unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hypoxia after extubation.\n\n Comparison is made with prior study of .\n\n Large bilateral pleural effusions are unchanged. Right upper lobe aeration\n has improved. Left upper lobe opacity medially is likely atelectasis.\n Cardiomediastinal contours are unchanged partially obscured by the pleural\n parenchymal abnormalities. Right IJ catheter tip is in the mid-to-lower SVC.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2199-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063757, "text": ", S. SICU-A 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypoxia after extubation\n REASON FOR THIS EXAMINATION:\n assess for PNA\n ______________________________________________________________________________\n PFI REPORT\n Improved aeration of the upper lobes. Large bilateral pleural effusions are\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2199-02-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1062652, "text": " 2:49 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm line placemetn\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man w new R IJ\n REASON FOR THIS EXAMINATION:\n confirm line placemetn\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Line placement.\n\n New right internal jugular catheter terminates in the mid superior vena cava.\n Examination otherwise unchanged with persistent partial collapse of right\n upper lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062809, "text": " 4:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval exam\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p colectomy for c/diff colitis\n REASON FOR THIS EXAMINATION:\n interval exam\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 62-year-old man with colectomy for C. diff colitis.\n\n Endotracheal tube, nasogastric tube, and central venous catheters are\n unchanged in position. There is improved aeration of the right upper lobe\n since the prior study. However, there is development of bilateral pleural\n effusions and bibasilar opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062584, "text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval et tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cdiff s/p colectomy\n REASON FOR THIS EXAMINATION:\n eval et tube\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube position.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6.5 cm above the carina at the level of the clavicular\n heads. There is newly developed right upper lobe atelectasis, most likely in\n the peri-intubation period. The cardiomediastinal silhouette otherwise is\n unchanged including the prominence of the right pulmonary vein that might be\n consistent with pulmonary hypertension. The left lung and the right lower\n lung are clear except for retrocardiac atelectasis. Free intraperitoneal air\n is due to recent colectomy.\n\n The findings were discussed with Dr. over the phone by Dr. \n at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063364, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?findings\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with acute desat\n REASON FOR THIS EXAMINATION:\n ?findings\n ______________________________________________________________________________\n FINAL REPORT\n CXR SINGLE PORTABLE FILM\n\n FINDINGS: The current film may be mislabeled as to the right and left side\n markers. The previously noted right IJ line that was on the right side on the\n current film appears to be on the left, this is most likely mislabeling the\n side of the film. Support lines are without change. There is increasing\n opacification of both hemithoraces, left greater than right, indicating\n layering bilateral pleural effusions as well as underlying atelectasis,\n especially on the left. Almost the entire left hemithorax appears opaque.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-01-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062482, "text": " 6:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with altered ms\n REASON FOR THIS EXAMINATION:\n eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:02 PM\n no acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass, mass\n effect, edema, or evidence of acute vascular territorial infarction.\n Ventricles and sulci are unchanged in size and configuration. Hypodensity in\n the left middle cranial fossa is stable, most consistent with arachnoid cyst.\n Bilateral vascular calcifications are stable. Small retention cyst\n in the left maxillary sinus is unchanged. Remaining visualized paranasal\n sinuses are normally aerated.\n\n IMPRESSION: No acute intracranial process. No significant change from\n .\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2199-01-31 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1062483, "text": " 6:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval acute process\n Field of view: 46 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with altered ms, hypotesion, h/o cdiff\n REASON FOR THIS EXAMINATION:\n eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:02 PM\n Worsened distal colonic wall thickening and edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, hypotension, and history of C. difficile\n infection.\n\n COMPARISON: and .\n\n TECHNIQUE: Volumetric CT acquisition of the abdomen and pelvis was performed\n following administration of oral and intravenous contrast.\n\n CT ABDOMEN: There is mild dependent bibasilar atelectasis. Coronary artery\n calcifications are noted.\n\n Several small intrahepatic subcentimeter hypodensities are unchanged, and\n likely represent simple cysts, but remain too small to definitively\n characterize, and are unchanged. Liver is otherwise unremarkable. The\n gallbladder is not visualized, presumably surgically absent. Pancreas,\n spleen, and adrenal glands are unremarkable. Gastrojejunostomy tube is\n unchanged in position. Intra-abdominal loops of small bowel are unremarkable.\n There is no bowel obstruction. There is no free air or free intraperitoneal\n fluid. Kidneys enhance and excrete contrast symmetrically. Bilateral renal\n cystic lesions too small to definitively characterize are unchanged.\n\n CT PELVIS: Marked wall thickening and edema in the sigmoid colon has worsened\n since previous exam, and now extends to the level of the splenic flexure. Mild\n pericolonic inflammatory stranding is unchanged. The rectum is also involved.\n Ascending and transverse colon are largely collapsed, and relatively normal in\n appearance. Pelvic loops of small bowel are unremarkable. Urinary bladder is\n decompressed with Foley catheter balloon in place. There is no free pelvic\n fluid. Scattered small pelvic lymph nodes do not meet CT criteria for\n pathologic enlargement.\n\n Marked atherosclerotic vascular calcifications throughout is unchanged. Right\n hip arthroplasty is stable in appearance. There is no new fracture. Diffuse\n osteopenia is unchanged.\n\n IMPRESSION: Interval worsening of distal colonic wall thickening and bowel\n wall edema, which now extends from the rectum proximally to the splenic\n flexure, compatible with proctocolitis. Findings are likely secondary to an\n infectious cause, especially in the context of the patient's clinical history,\n (Over)\n\n 6:43 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval acute process\n Field of view: 46 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n but an inflammatory etiology is not excluded. No evidence of perforation, or\n obstruction.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2199-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063975, "text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with increased secretions, rising wbc\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable AP chest in comparison to prior day.\n\n HISTORY: Rising WBC count.\n\n FINDINGS: There is no significant interval change in bilateral pleural\n effusions with subjacent atelectasis. The right IJ central line terminates in\n the SVC/right atrial junction. Cardiac size is normal. There appears to be\n mild congestion unchanged from prior study.\n\n IMPRESSION:\n\n No significant interval change in congestion and bilateral effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-02-04 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 1063045, "text": " 9:38 AM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: R/O LAP PADS GJ TUBE PLACE\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n KUB ON \n\n HISTORY: Rule out lap pads J G-tube placement.\n\n FINDINGS: The J G-tube is visualized with contrast in the small bowel. It is\n difficult to discern as some of the contrast is also in the colon. This is\n likely due to rapid passage of the contrast as the tube appears to be within\n the small bowel. NG tube is present. Right upper quadrant clips and chain\n sutures in the pelvis are again seen.\n\n\n" }, { "category": "ECG", "chartdate": "2199-02-02 00:00:00.000", "description": "Report", "row_id": 223170, "text": "Sinus rhythm\nRight bundle branch block\nLeft anterior fascicular block\nGeneralized low voltage\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , sinus tachycardia rate slower, ventricular\nectopy nor seen, and generalized low voltage now present\n\n" }, { "category": "ECG", "chartdate": "2199-02-01 00:00:00.000", "description": "Report", "row_id": 223171, "text": "Sinus tachycardia. Ventricular premature beats. Right superior axis.\nRight bundle-branch block. Clinical correlation is suggested. Since the\nprevious tracing of the rate has increased. Axis is more right\nsuperior which probably accounts for the change in R wave progression.\nClinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2181-05-06 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 959889, "text": " 3:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess OG tube location.\n Admitting Diagnosis: ALTERED MENTAL STATUS/ GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CHF and MS changes, now with OG tube.\n\n REASON FOR THIS EXAMINATION:\n Assess OG tube location.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF AT 15:35.\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: OG tube placement.\n\n Respiratory motion blurs detail. Orogastric tube coils within the stomach but\n distal tip is not confidently visualized. There is otherwise no substantial\n change in the appearance of the chest or upper abdomen since the prior study\n of a few hours earlier, allowing for the presence of motion artifact.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-05-06 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 959881, "text": " 1:45 PM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: 1. Please assesss for ascites (if possible please mark for\n Admitting Diagnosis: ALTERED MENTAL STATUS/ GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with 2 day history of progressive encephalopathy, possibly\n alcoholic, also with elevated Tbili\n REASON FOR THIS EXAMINATION:\n 1. Please assesss for ascites (if possible please mark for tap)2. Please\n assess for organomegaly 3. Please assess biliary system as bili elevated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Two days of progressive encephalopathy with elevated T-bilirubin.\n Please assess for ascites and organomegaly.\n\n No prior examinations.\n\n ABDOMINAL ULTRASOUND: This exam was somewhat limited by patient's respiratory\n motion. Liver is coarse and echogenic, consistent with chronic liver disease.\n No surface nodularity identified. The common bile duct was not able to be\n identified. The gallbladder has numerous shadowing gallstones with no wall\n edema or pericholecystic fluid to suggest cholecystitis. There is a large\n recanalized umbilical vein, also suggestive of chronic liver disease. The\n spleen is enlarged measuring 16 cm. There is no ascites. Portal vein is\n patent with anterograde flow. The right kidney measures 10.4 cm and left\n kidney measures 11.9 cm with no hydronephrosis, masses or stones.\n\n Doppler examination of the liver demonstrates normal waveforms in the main\n portal vein and right and left portal veins as well as normal arterial\n waveforms in the main hepatic artery. The hepatic veins also demonstrate\n normal cardiac variation.\n\n IMPRESSION:\n 1. Coarsened liver echotexture, splenomegaly, and a large recanalized\n umbilical vein, all findings suggestive of chronic liver disease. No evidence\n of ascites. The portal vein is patent with antegrade flow.\n 2. Cholelithiasis without cholecystitis.\n\n Findings were discussed with Dr. at 8 p.m. on .\n\n\n" }, { "category": "Echo", "chartdate": "2181-05-07 00:00:00.000", "description": "Report", "row_id": 59995, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 171\nBSA (m2): 1.95 m2\nBP (mm Hg): 172/57\nHR (bpm): 56\nStatus: Inpatient\nDate/Time: at 12:05\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 ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Overall normal\nLVEF (>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. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is mildly dilated. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets are moderately thickened. There is mild aortic valve\nstenosis (area 1.2-1.9cm2). Mild (1+) 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 moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the aortic valve\ngradient is now higher and estimated pulmonary artery systolic pressure is now\nhigher.\n\n\n" }, { "category": "ECG", "chartdate": "2181-05-06 00:00:00.000", "description": "Report", "row_id": 106455, "text": "Sinus bradycardia. Intraventricular conduction delay. Left ventricular\nhypertrophy with secondary ST-T wave abnormalities. No previous tracing\navailable for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-07 00:00:00.000", "description": "Report", "row_id": 1430717, "text": "cv: hr 55-62 sb-nsr no ectopy. sbp increased to 170-180's..briefly decreased to 166/ after recieving scheduled dose lopressor via ng tube sbp increased again to 186/ ho notified and hydralazine 25 mg po ordered. dose given at 0530.\n\nresp: lungs clear. o2 sats 96-98 % on 2 l nc.\n\ngi: npo except for ice chips.ng tube in place,clamped, used for meds. positive bowel sounds,abdomnen soft.lactulose via ng tube.. large bm formed, soft, guiac negative\n\ngu: urine output improved after 500 cc ns bolus given at onset of shift..uo30-80 cc/hr\n\nneuro: pt alert, sleeping intermittently. Oriented to person and place but unable to state year or date. speech garbled at times.cooperative. mae to command.\n\nintegumentary: left forearm skin tear cleansed and allevyn dressing changed for a moderate amount sanguinous drainage. r upper arm has an allevyn dressing which is dry and intact. r elbow has a very small skin prick which is weeping small amount of serosanguinous.. cleansed and covered with a tegaderm.\n\niv access: # 18 gauge in left antecub.# 18 in r antecub.\n\nid: afebrile. wbc wnl. bl cx results pending and urine cx results pending.\n\nlabs: tbili inc 4.3, dbil 0.9, LDH increase to 301, ast 41. cr 1.1/bun 36 , k=4.4\n" }, { "category": "Nursing/other", "chartdate": "2181-05-07 00:00:00.000", "description": "Report", "row_id": 1430718, "text": "NPN 0700-1900\nneuro: Pt. alert and oriented x2.(person and place, occ will get the date wrong). Per family Pt.'s MS is improving. MAE. Cont. on Lactulose for encephalopathy. Wrist restraints on as remainder not to pull put NGT.\n\nresp; remains on 2L NC with O2 sat 95-97%. RR easy. LS with occ. cracels but Pt. has intersticial fibrosis. No resp. distress this shift.\n\nCV: Cont. with HTN. Started on Aldactone and Lasix to decrease BP. On Metoprolol. BP 160's-180's/60's-70's, HR 50's-60's NS with no ectopy noted this shift. No edema. Cardiac echo at bedside today to evaluate pulmonary HTN and R heart failure. Results pending.\n\nGI: Cont. being worked up for hepatitis by hepathology. Amonial level 144 at 5/6. No amonia today. Cont. on Lactulose and had 2 loose OB- stools this shift. Abd. softly distended BS+. NGT in place for meds for ? aspiration. Bedside speach and swallow eval done and inconclusive. Pt. needs video swallow in AM.\n\nGU; Foley cath in place and draining amber urine. Started on Aldactone and Lasix with improvement in UO.\n\nID: Urine cx. + for staph aureus coag+. On PO Levaquin. Blood cx. from pending.\n\nSocial: Pt.'s son and wife in today visiting. Both updated on POC. Pt. c/o and awaiting bed. Pt. is a full code.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-06 00:00:00.000", "description": "Report", "row_id": 1430716, "text": "MICU NPN Admit note\n\n77y/o male who presents with mental status changes. This past week pt's family reports increse in lethargy,confusion, and garbled speech. Pt was seen by PCP and he was sent for CT which was negative for bleed. This morning, pt's son found him to be minimally responsive, confused, and incontinent of bowels and bladder. In EW, pt was given 2L NS fluid bolus (lactate 3.5), levoquin, lactulose, Blood and urine sent for culture. Pt transferred to MICU for further management.\n\nPMH: CHF, Interstitial Fibrosis\n\nNKDA\n\nNeuro: Upon arrival to MICU, pt confused and oriented to person only. He remains oriented x 1 but is having moments of lucidity more often. Initially, Speech garbled although seems to be clearing. Pt follows commands consistantly. Lactulose being given for confusion. urine tox screen sent and negative. Per Son, , Pt is usually oriented, drives, and does self ADLs.\n\nResp: Pt h/o interstitial fibrosis on home O2. Pt on 2L NC here satting 98%. LS CTA.\n\nCV: HR 60's. NSR, no ectopy noted. BP 141-165/57-59. PO lopresser given. Echo ordered. Hct 36.6%. Plts 65 (trending down). NS infusing @ 80cc/hr x 2 liters.\n\nGI: NPO except ice chips. NGT in place and confirmed by CXr and Dr. . Meds being given via NGT but if pt appears more awake would give them PO. Pt being given lactulose. 1 Medium BM, guiac negative. Pt was able to ask for bedpan. pt being w/u for liver failure. Abdomenal US done. Results pnding. Heptalogy following. hepatitis panels sent and pnding.\n\nGU: urine output tapering off.\n\nID: urine positive for nitrates and bacteria. Pt to start on ciprofloxacin when available from pharmacy. Lactate down to 2.3.\n\nSkin: Rt upper arm with large skin tear. Wound cleanser nad allovyn dressing placed. Site is bleeding. Left upper arm and elbow with skin tear. Pt also appears to be bleeding from urethra.\n\nSocial: Lives at home independently with wife who has alzheimers dz. Son, , is the spokesperson (he does not think pt has HCP filled out). Phone # of son on board in pt's room.\n\nDispo: Remain in MICU. Full code\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2146-08-14 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 338789, "text": "Chief Complaint: Abdominal pain.\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation.\n On arrival to the ER he was afebrile, tachy to 103, tachypneic to\n 24, SBP in the high 90s, satting 90% on RA. Because of the abdominal\n pain and the CT findings, he was aggressively fluid resuscitated\n ended up getting five liters of fluid. RUQ U/S didn\nt reveal any acute\n findings. However, he was noted to have a positive UA with large blood,\n nitrite positive, 6-10 WBCs, 21-50 RBCs and many bacteria but LE\n negative. He had a peripheral leukocytosis of 16 and acute on chronic\n renal failure with a creatinine of 2.4 (baseline ~1.7). Urology\n recommended decompressing the hydronephrosis with IR assistance. He\n received empiric Vanc and Zosyn in the ER. He underwent the perc\n nephrostomy tube placement and was given a dose of Cipro in IR; he was\n then transferred to the MICU for further care.\n He currently is pain-free. He denies any intercurrent fevers, chills.\n He does endorse feeling fatigued and has been using a walker at home.\n He reports intermittent hematuria but no other urinary symptoms. No\n diarrhea, brbpr. .\n Allergies:\n Codeine\n Unknown\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions: None.\n Other ICU medications:\n Other medications:\n Home meds:\n Oxycontin\n Colace\n Past medical history:\n Family history:\n Social History:\n 1) Bladder cancer diagnosed in s/p surgery x 2, BCG therapy\n in . Recurrence again in with extensive metastases (liver,\n left femur and bladder bed mass compressing left ureter.) Recently\n evaluated by Med Onc.\n 2) Distant left inguinal hernia repair.\n 3) H/o nephrolithiasis in distant past.\n 4) 2 cm speculated mass in superior segment of LLL.\n 5) Significant tobacco use.\n No h/o malignancy.\n Occupation: Retired clerical\n worker\n Drugs: None\n Tobacco: Several pack-a-day smoker x 45 years, >100 pack-year history\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n Cardiac: Denies any chest pain, palpitations, pressure,\n orthopnea, PND.\n Pulmonary: Denies cough, shortness of breath, wheezing.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr,\n melena.\n Renal: Denies dysuria, hematuria.\n Skin: Denies rash.\n Neuro: Denies headache, weakness, focal numbness.\n Flowsheet Data as of 01:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (83 - 86) bpm\n BP: 100/61(70) {100/59(69) - 123/64(78)} mmHg\n RR: 19 (18 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,217 mL\n PO:\n TF:\n IVF:\n 217 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n General: NAD, comfortable, breathing comfortably.\n HEENT: PERRL. Arcus. Anicteric sclera. Dry MM, OP otherwise clear.\n CV: S1 S2 RRR w/o appreciable m/r/g\ns. No heave.\n Lungs: CTA bilaterally with bibasilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns. Soft. Non-tender except for RUQ; non-distended. No\n masses noted, although liver ~2 cm below costal margin.\n Ext: No edema. Positive clubbing.\n Neuro: Arousable to voice, mildy confused likely having received\n versed and fentanyl in IR. No focal deficits on gross motor exam.\n Labs / Radiology\n 8\n 103\n 5.6\n 140\n 16.3\n [image002.jpg] INR 1.3\n ABG 7.33 / 35 / 130\n Lactate 3.0\n 2.5\n ALT 142\n AST 367\n Alk phos 548\n T bili 2.3\n Albumin 2.1\n LDH 8690\n Lipase 167\n pCXR No e/o infiltrate, edema, or effusion. Possible cystic structure\n in the right hilum that could be a confluence of vessels.\n EKG (): Sinus tach, inferior Q\ns, RBBB. No priors. .\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n 4) F/E/N: Regular diet. Follow\nlytes, replete as needed. Would hold on\n further IVF at this time.\n 5) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:00 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": "2146-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338792, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE, abd CT revealled obstructing Bladder tumor. recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n s/p perc nephrostomy today and admitted to the MICU for further\n management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n" }, { "category": "Nursing", "chartdate": "2146-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338800, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE, abd CT revealled obstructing Bladder tumor. recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL\n Sepsis, Severe (with organ dysfunction) urosepsis\n Assessment:\n Afebrile t-max 99, hemodynamically stable. WBC 16.3, lactate 3.0/2.4\n Action:\n Fluid resuscitation, abx vanco and zosyn in ED started ciprofloxin\n Response:\n + UTI, Blood cultures pending\n Plan:\n Follow cultures, WBC, temp, clinical status.\n Cancer (Malignant Neoplasm), Other obstructing Bladder Mass, s/p perc\n nephrostomy \n Assessment:\n Foley cath anuric, BUN creat 68/2.4. s/p L nephrostomy tube placement\n passing hematuria.\n Action:\n To IR @ 1000 for L percutaneous nephrostomy tube placement\n Response:\n ^u/o\n Plan:\n Flush nephrostomy tube q8hrs\n" }, { "category": "Physician ", "chartdate": "2146-08-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 338808, "text": "Chief Complaint: abdominal pain\n HPI:\n 81 yo male with presumed COPD and recently diagnosed metastatic bladder\n CA with known left hydronephrosis presents from OSH ED after\n complaining of abd pain. The pt reports that he was in his usual state\n of health until mid-day on the day PTA. At that point, he noted the\n onset of RLQ abd pain that was non-radiating and intermittently sharp\n and dull. He presented to the ED at - where he was afebrile\n but noted to appear unwell and have an SBP in the 90s with associcated\n sinus tachycardia. A CT scan there demonstrated left hydronephrosis and\n a question of gallbladder distention.\n In the ED, initial vitals were 97.2, 103, 24, 98/68 and 90% RA.\n An abd ultrasound was obtained in the ED. This study did not show gall\n bladder abdnormalities but did demonstrate extensive hepatic mets. He\n was given emperic doses of Zosyn and vancomycin as well as 5L NS. A\n urology consultation was obtained given the pt's hydronephrosis and a\n positive UA. There was a concern for left sided upper urinary tract\n infection and urgent percutaneous nephrostomy tube placement was\n advised; this was performed by IR immediately after the pt's arrival to\n the MICU. A VQ scan was also obtained given the pt's tachycardia and\n relative hypoxia; the results of this study are pending.\n ROS was otherwise essentially negative. The pt endorsed intermittent\n hemature but denied recent unintended weight loss, fevers, night\n sweats, chills, headaches, dizziness or vertigo. No changes in hearing\n or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground\n emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea,\n constipation, steatorrhea, melena, hematochezia, cough, hemoptysis,\n wheezing, shortness of breath, chest pain, palpitations, dyspnea on\n exertion, increasing lower extremity swelling, orthpnea, paroxysmal\n nocturnal dyspnea, leg pain while walking, joint pain.\n Medications at Home:\n oxycontin PRN\n colace\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n multiple papillary bladder tumors\n --first dx in \n --s/p BCG therapy\n --concern for mets to mid left femur, known extensive liver mets\n renal stones many years ago\n s/p left inguinal hernia repair\n lung nodule concerning for possible malignancy noted on CT scan\n No FH of malignancy or other heritable disease. Both parents lived to\n advanced age.\n Occupation: retired clerical worker\n Drugs: denies\n Tobacco: smoked multiple PPD from age 14 to 61\n Alcohol: denies\n Other:\n Review of systems:\n Flowsheet Data as of 04:25 PM\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: 36.3\nC (97.4\n HR: 91 (83 - 91) bpm\n BP: 106/60(71) {100/37(53) - 123/65(78)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,595 mL\n PO:\n 350 mL\n TF:\n IVF:\n 245 mL\n Blood products:\n Total out:\n 0 mL\n 405 mL\n Urine:\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,190 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n Physical Examination\n General: Awake and alert though mildly sleepy. NAD, pleasant,\n appropriate, cooperative.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in\n OP.\n Neck: Supple, no significant JVD or carotid bruits appreciated.\n Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi.\n Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: Trace edema, 2+ radial and DP pulses b/l\n Skin: No rashes or lesions noted.\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout. No nystagmus, dysarthria, intention or action tremor.\n 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle\n jerks bilaterally. Plantar response was flexor bilaterally.\n Labs / Radiology\n 440\n 110\n 2.4\n 67\n 17\n 107\n 5.1\n 140\n 41.5\n 16.3\n [image002.jpg]\n Other labs: ALT / AST:142/367, Alk Phos / T Bili:548/2.3, Amylase /\n Lipase:/167\n Imaging: CXR:\n The cardiomediastinal contour is normal. The heart is not enlarged.\n There is linear platelike atelectasis at the left lung base. The lungs\n are otherwise clear. Osseous structures are unremarkable.\n IMPRESSION: No evidence of focal consolidation on this single view.\n Abd US\n 1. Innumerable hepatic metastases from bladder cancer.\n 2. Cholelithiasis without evidence of cholecystitis.\n 3. No evidence of intrahepatic biliary ductal dilatation; normal size\n of CBD.\n ECG: ST at 100. Leftward axis devation; normal intervals. RBBB and\n LAFB. Q waves inferiorly. No priors available for comparison.\n Assessment and Plan\n 81 yo male presenting with bladder cancer, found to have abd pain,\n tachycardia and borderline blood pressure, now s/p perc nephrostomy\n tube drainage of left hydronephrosis.\n #Sepsis, probable urinary source: Pt meets criteria for sepsis although\n currently does not have evidence of shock.\n -pt has been aggressively volume repleted; will trend\n -continue IV Cipro for UTI\n #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH\n approximately one week ago, now further elevated. Some baseline renal\n dysfunction expected given pt's obstruction; suspect that acuity of\n further obstruction resulting in additional failure. Pt now s/p perc\n drainage placement and volume repletion. Will trend and check urine\n lytes if no improvement.\n #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic\n mets. Trend hepatic function and coagulation status closely.\n #Question PE: Initial concern for PE based on tachycardia and\n borderline oxygen saturation. Tachycardia has now improved; oxygen\n saturations remain slightly low. Overall clinical suspicion for PE is\n low, however this remains a possibility.\n -f/u VQ read\n -consider checking LENIs\n #Abd pain: Has resolved. Likely secondary to UTI, although numerous\n other etiologies are certainly possible. CT without evidence of acute\n process to explain pain. Plan to trend clinically with serial abd\n exams.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-08-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 338809, "text": "Chief Complaint: abdominal pain\n HPI:\n 81 yo male with presumed COPD and recently diagnosed metastatic bladder\n CA with known left hydronephrosis presents from OSH ED after\n complaining of abd pain. The pt reports that he was in his usual state\n of health until mid-day on the day PTA. At that point, he noted the\n onset of RLQ abd pain that was non-radiating and intermittently sharp\n and dull. He presented to the ED at - where he was afebrile\n but noted to appear unwell and have an SBP in the 90s with associcated\n sinus tachycardia. A CT scan there demonstrated left hydronephrosis and\n a question of gallbladder distention.\n In the ED, initial vitals were 97.2, 103, 24, 98/68 and 90% RA.\n An abd ultrasound was obtained in the ED. This study did not show gall\n bladder abdnormalities but did demonstrate extensive hepatic mets. He\n was given emperic doses of Zosyn and vancomycin as well as 5L NS. A\n urology consultation was obtained given the pt's hydronephrosis and a\n positive UA. There was a concern for left sided upper urinary tract\n infection and urgent percutaneous nephrostomy tube placement was\n advised; this was performed by IR immediately after the pt's arrival to\n the MICU. A VQ scan was also obtained given the pt's tachycardia and\n relative hypoxia; the results of this study are pending.\n ROS was otherwise essentially negative. The pt endorsed intermittent\n hemature but denied recent unintended weight loss, fevers, night\n sweats, chills, headaches, dizziness or vertigo. No changes in hearing\n or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground\n emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea,\n constipation, steatorrhea, melena, hematochezia, cough, hemoptysis,\n wheezing, shortness of breath, chest pain, palpitations, dyspnea on\n exertion, increasing lower extremity swelling, orthpnea, paroxysmal\n nocturnal dyspnea, leg pain while walking, joint pain.\n Medications at Home:\n oxycontin PRN\n colace\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n multiple papillary bladder tumors\n --first dx in \n --s/p BCG therapy\n --concern for mets to mid left femur, known extensive liver mets\n renal stones many years ago\n s/p left inguinal hernia repair\n lung nodule concerning for possible malignancy noted on CT scan\n No FH of malignancy or other heritable disease. Both parents lived to\n advanced age.\n Occupation: retired clerical worker\n Drugs: denies\n Tobacco: smoked multiple PPD from age 14 to 61\n Alcohol: denies\n Other:\n Flowsheet Data as of 04:25 PM\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: 36.3\nC (97.4\n HR: 91 (83 - 91) bpm\n BP: 106/60(71) {100/37(53) - 123/65(78)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,595 mL\n PO:\n 350 mL\n TF:\n IVF:\n 245 mL\n Blood products:\n Total out:\n 0 mL\n 405 mL\n Urine:\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,190 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n Physical Examination\n General: Awake and alert though mildly sleepy. NAD, pleasant,\n appropriate, cooperative.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in\n OP.\n Neck: Supple, no significant JVD or carotid bruits appreciated.\n Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi.\n Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: Trace edema, 2+ radial and DP pulses b/l\n Skin: No rashes or lesions noted.\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout. No nystagmus, dysarthria, intention or action tremor.\n 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle\n jerks bilaterally. Plantar response was flexor bilaterally.\n Labs / Radiology\n 440\n 110\n 2.4\n 67\n 17\n 107\n 5.1\n 140\n 41.5\n 16.3\n [image002.jpg]\n Other labs: ALT / AST:142/367, Alk Phos / T Bili:548/2.3, Amylase /\n Lipase:/167\n Imaging: CXR:\n The cardiomediastinal contour is normal. The heart is not enlarged.\n There is linear platelike atelectasis at the left lung base. The lungs\n are otherwise clear. Osseous structures are unremarkable.\n IMPRESSION: No evidence of focal consolidation on this single view.\n Abd US\n 1. Innumerable hepatic metastases from bladder cancer.\n 2. Cholelithiasis without evidence of cholecystitis.\n 3. No evidence of intrahepatic biliary ductal dilatation; normal size\n of CBD.\n ECG: ST at 100. Leftward axis devation; normal intervals. RBBB and\n LAFB. Q waves inferiorly. No priors available for comparison.\n Assessment and Plan\n 81 yo male presenting with bladder cancer, found to have abd pain,\n tachycardia and borderline blood pressure, now s/p perc nephrostomy\n tube drainage of left hydronephrosis.\n #Sepsis, probable urinary source: Pt meets criteria for sepsis although\n currently does not have evidence of shock.\n -pt has been aggressively volume repleted; will trend\n -continue IV Cipro for UTI\n #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH\n approximately one week ago, now further elevated. Some baseline renal\n dysfunction expected given pt's obstruction; suspect that acuity of\n further obstruction resulting in additional failure. Pt now s/p perc\n drainage placement and volume repletion. Will trend and check urine\n lytes if no improvement.\n #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic\n mets. Trend hepatic function and coagulation status closely.\n #Question PE: Initial concern for PE based on tachycardia and\n borderline oxygen saturation. Tachycardia has now improved; oxygen\n saturations remain slightly low. Overall clinical suspicion for PE is\n low, however this remains a possibility.\n -f/u VQ read\n -consider checking LENIs\n #Abd pain: Has resolved. Likely secondary to UTI, although numerous\n other etiologies are certainly possible. CT without evidence of acute\n process to explain pain. Plan to trend clinically with serial abd\n exams.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled\n Lines:\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PO diet\n Code status: full\n Disposition: MICU\n" }, { "category": "Physician ", "chartdate": "2146-08-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 338964, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 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 07:26 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: 36\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///16/\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 317 K/uL\n 12.7 g/dL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338780, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, \n transferred to ED ARF /urology. Upon arrival was found to be\n hypoxic on R/A sat 80% tachypneic, tachycardic, hypotensive SBP 90,\n afebrile foley placed for scant dk brown urine, recieved 5L NS,\n lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan r/o PE, abd CT\n revealled obstructing Bladder tumor. recieved abx vancomycin/Zosyn,\n recieved Morphine 2mg IV x2 for pain. Admitted to MICU for sepsis and\n further eval and monitoring.\n" }, { "category": "Physician ", "chartdate": "2146-08-14 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 338784, "text": "Chief Complaint:\n HPI:\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\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 01:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (83 - 86) bpm\n BP: 100/61(70) {100/59(69) - 123/64(78)} mmHg\n RR: 19 (18 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,217 mL\n PO:\n TF:\n IVF:\n 217 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\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 ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:00 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": "2146-08-14 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 338787, "text": "Chief Complaint: Abdominal pain.\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation.\n On arrival to the ER he was afebrile, tachy to 103, tachypneic to\n 24, SBP in the high 90s, satting 90% on RA. Because of the abdominal\n pain and the CT findings, he was aggressively fluid resuscitated\n ended up getting five liters of fluid. RUQ U/S didn\nt reveal any acute\n findings. However, he was noted to have a positive UA with large blood,\n nitrite positive, 6-10 WBCs, 21-50 RBCs and many bacteria but LE\n negative. He had a peripheral leukocytosis of 16 and acute on chronic\n renal failure with a creatinine of 2.4 (baseline ~1.7). Urology\n recommended decompressing the hydronephrosis with IR assistance. He\n received empiric Vanc and Zosyn in the ER. He underwent the perc\n nephrostomy tube placement and was given a dose of Cipro in IR; he was\n then transferred to the MICU for further care.\n He currently is pain-free. He denies any intercurrent fevers, chills.\n He does endorse feeling fatigued and has been using a walker at home.\n He reports intermittent hematuria but no other urinary symptoms. No\n diarrhea, brbpr. .\n Allergies:\n Codeine\n Unknown\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions: None.\n Other ICU medications:\n Other medications:\n Home meds:\n Oxycontin\n Colace\n Past medical history:\n Family history:\n Social History:\n 1) Bladder cancer diagnosed in s/p surgery x 2, BCG therapy\n in . Recurrence again in with extensive metastases (liver,\n left femur and bladder bed mass compressing left ureter.) Recently\n evaluated by Med Onc.\n 2) Distant left inguinal hernia repair.\n 3) H/o nephrolithiasis in distant past.\n 4) 2 cm speculated mass in superior segment of LLL.\n 5) Significant tobacco use.\n No h/o malignancy.\n Occupation: Retired clerical\n worker\n Drugs: None\n Tobacco: Several pack-a-day smoker x 45 years, >100 pack-year history\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n Cardiac: Denies any chest pain, palpitations, pressure,\n orthopnea, PND.\n Pulmonary: Denies cough, shortness of breath, wheezing.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr,\n melena.\n Renal: Denies dysuria, hematuria.\n Skin: Denies rash.\n Neuro: Denies headache, weakness, focal numbness.\n Flowsheet Data as of 01:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (83 - 86) bpm\n BP: 100/61(70) {100/59(69) - 123/64(78)} mmHg\n RR: 19 (18 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,217 mL\n PO:\n TF:\n IVF:\n 217 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n General:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 8\n 103\n 5.6\n 140\n 16.3\n [image002.jpg] INR 1.3\n ABG 7.33 / 35 / 130\n Lactate 3.0\n 2.5\n ALT 142\n AST 367\n Alk phos 548\n T bili 2.3\n Albumin 2.1\n LDH 8690\n Lipase 167\n pCXR No e/o infiltrate, edema, or effusion. Possible cystic structure\n in the right hilum that could be a confluence of vessels.\n EKG (): Sinus tach, inferior Q\ns, RBBB. No priors. .\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n 4) F/E/N: Regular diet. Follow\nlytes, replete as needed. Would hold on\n further IVF at this time.\n 5) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:00 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": "2146-08-14 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 338839, "text": "Chief Complaint: Abdominal pain.\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation.\n On arrival to the ER he was afebrile, tachy to 103, tachypneic to\n 24, SBP in the high 90s, satting 90% on RA. Because of the abdominal\n pain and the CT findings, he was aggressively fluid resuscitated\n ended up getting five liters of fluid. RUQ U/S didn\nt reveal any acute\n findings. However, he was noted to have a positive UA with large blood,\n nitrite positive, 6-10 WBCs, 21-50 RBCs and many bacteria but LE\n negative. He had a peripheral leukocytosis of 16 and acute on chronic\n renal failure with a creatinine of 2.4 (baseline ~1.7). Urology\n recommended decompressing the hydronephrosis with IR assistance. He\n received empiric Vanc and Zosyn in the ER. He underwent the perc\n nephrostomy tube placement and was given a dose of Cipro in IR; he was\n then transferred to the MICU for further care.\n He currently is pain-free. He denies any intercurrent fevers, chills.\n He does endorse feeling fatigued and has been using a walker at home.\n He reports intermittent hematuria but no other urinary symptoms. No\n diarrhea, brbpr. .\n Allergies:\n Codeine\n Unknown\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions: None.\n Other ICU medications:\n Other medications:\n Home meds:\n Oxycontin\n Colace\n Past medical history:\n Family history:\n Social History:\n 1) Bladder cancer diagnosed in s/p surgery x 2, BCG therapy\n in . Recurrence again in with extensive metastases (liver,\n left femur and bladder bed mass compressing left ureter.) Recently\n evaluated by Med Onc.\n 2) Distant left inguinal hernia repair.\n 3) H/o nephrolithiasis in distant past.\n 4) 2 cm speculated mass in superior segment of LLL.\n 5) Significant tobacco use.\n No h/o malignancy.\n Occupation: Retired clerical\n worker\n Drugs: None\n Tobacco: Several pack-a-day smoker x 45 years, >100 pack-year history\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n Cardiac: Denies any chest pain, palpitations, pressure,\n orthopnea, PND.\n Pulmonary: Denies cough, shortness of breath, wheezing.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr,\n melena.\n Renal: Denies dysuria, hematuria.\n Skin: Denies rash.\n Neuro: Denies headache, weakness, focal numbness.\n Flowsheet Data as of 01:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (83 - 86) bpm\n BP: 100/61(70) {100/59(69) - 123/64(78)} mmHg\n RR: 19 (18 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,217 mL\n PO:\n TF:\n IVF:\n 217 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n General: NAD, comfortable, breathing comfortably.\n HEENT: PERRL. Arcus. Anicteric sclera. Dry MM, OP otherwise clear.\n CV: S1 S2 RRR w/o appreciable m/r/g\ns. No heave.\n Lungs: CTA bilaterally with bibasilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns. Soft. Non-tender except for RUQ; non-distended. No\n masses noted, although liver ~2 cm below costal margin.\n Ext: No edema. Positive clubbing.\n Neuro: Arousable to voice, mildy confused likely having received\n versed and fentanyl in IR. No focal deficits on gross motor exam.\n Labs / Radiology\n 8\n 103\n 5.6\n 140\n 16.3\n [image002.jpg] INR 1.3\n ABG 7.33 / 35 / 130\n Lactate 3.0\n 2.5\n ALT 142\n AST 367\n Alk phos 548\n T bili 2.3\n Albumin 2.1\n LDH 8690\n Lipase 167\n pCXR No e/o infiltrate, edema, or effusion. Possible cystic structure\n in the right hilum that could be a confluence of vessels.\n EKG (): Sinus tach, inferior Q\ns, RBBB. No priors. .\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n 4) F/E/N: Regular diet. Follow\nlytes, replete as needed. Would hold on\n further IVF at this time.\n 5) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:00 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": "2146-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338851, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE, abd CT revealled obstructing Bladder tumor. recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL\n Sepsis, Severe (with organ dysfunction) urosepsis\n Assessment:\n Afebrile t-max 99, hemodynamically stable. WBC 16.3, lactate 3.0/2.4\n Action:\n Fluid resuscitation, abx vanco and zosyn in ED started ciprofloxin\n Response:\n + UTI, Blood cultures pending\n Plan:\n Follow cultures, WBC, temp, clinical status.\n Cancer (Malignant Neoplasm), Other obstructing Bladder Mass, s/p perc\n nephrostomy \n Assessment:\n Foley cath anuric to oliguric, BUN creat 68/2.4. s/p L nephrostomy\n tube placement passing hematuria.\n Action:\n To IR @ 1000 for L percutaneous nephrostomy tube placement\n Response:\n ^u/o hematuria from nephrostomy, foley u/o 20-30cc/hr\n Plan:\n Flush nephrostomy tube q8hrs, expect hematuria for 4-5 days per IR\n" }, { "category": "Physician ", "chartdate": "2146-08-14 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 338862, "text": "Chief Complaint: Abdominal pain.\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation.\n On arrival to the ER he was afebrile, tachy to 103, tachypneic to\n 24, SBP in the high 90s, satting 90% on RA. Because of the abdominal\n pain and the CT findings, he was aggressively fluid resuscitated\n ended up getting five liters of fluid. RUQ U/S didn\nt reveal any acute\n findings. However, he was noted to have a positive UA with large blood,\n nitrite positive, 6-10 WBCs, 21-50 RBCs and many bacteria but LE\n negative. He had a peripheral leukocytosis of 16 and acute on chronic\n renal failure with a creatinine of 2.4 (baseline ~1.7). Urology\n recommended decompressing the hydronephrosis with IR assistance. He\n received empiric Vanc and Zosyn in the ER. He underwent the perc\n nephrostomy tube placement and was given a dose of Cipro in IR; he was\n then transferred to the MICU for further care.\n He currently is pain-free. He denies any intercurrent fevers, chills.\n He does endorse feeling fatigued and has been using a walker at home.\n He reports intermittent hematuria but no other urinary symptoms. No\n diarrhea, brbpr. .\n Allergies:\n Codeine\n Unknown\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions: None.\n Other ICU medications:\n Other medications:\n Home meds:\n Oxycontin\n Colace\n Past medical history:\n Family history:\n Social History:\n 1) Bladder cancer diagnosed in s/p surgery x 2, BCG therapy\n in . Recurrence again in with extensive metastases (liver,\n left femur and bladder bed mass compressing left ureter.) Recently\n evaluated by Med Onc.\n 2) Distant left inguinal hernia repair.\n 3) H/o nephrolithiasis in distant past.\n 4) 2 cm speculated mass in superior segment of LLL.\n 5) Significant tobacco use.\n No h/o malignancy.\n Occupation: Retired clerical\n worker\n Drugs: None\n Tobacco: Several pack-a-day smoker x 45 years, >100 pack-year history\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n Cardiac: Denies any chest pain, palpitations, pressure,\n orthopnea, PND.\n Pulmonary: Denies cough, shortness of breath, wheezing.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr,\n melena.\n Renal: Denies dysuria, hematuria.\n Skin: Denies rash.\n Neuro: Denies headache, weakness, focal numbness.\n Flowsheet Data as of 01:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (83 - 86) bpm\n BP: 100/61(70) {100/59(69) - 123/64(78)} mmHg\n RR: 19 (18 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 5,217 mL\n PO:\n TF:\n IVF:\n 217 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,117 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n General: NAD, comfortable, breathing comfortably.\n HEENT: PERRL. Arcus. Anicteric sclera. Dry MM, OP otherwise clear.\n CV: S1 S2 RRR w/o appreciable m/r/g\ns. No heave.\n Lungs: CTA bilaterally with bibasilar crackles. No wheezing. Good air\n movement.\n Ab: Positive BS\ns. Soft. Non-tender except for RUQ; non-distended. No\n masses noted, although liver ~2 cm below costal margin.\n Ext: No edema. Positive clubbing.\n Neuro: Arousable to voice, mildy confused likely having received\n versed and fentanyl in IR. No focal deficits on gross motor exam.\n Labs / Radiology\n 8\n 103\n 5.6\n 140\n 16.3\n [image002.jpg] INR 1.3\n ABG 7.33 / 35 / 130\n Lactate 3.0\n 2.5\n ALT 142\n AST 367\n Alk phos 548\n T bili 2.3\n Albumin 2.1\n LDH 8690\n Lipase 167\n pCXR No e/o infiltrate, edema, or effusion. Possible cystic structure\n in the right hilum that could be a confluence of vessels.\n EKG (): Sinus tach, inferior Q\ns, RBBB. No priors. .\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n 4) F/E/N: Regular diet. Follow\nlytes, replete as needed. Would hold on\n further IVF at this time.\n 5) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:00 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 ------ Protected Section ------\n Critical Care Staff Addendum\n 6:30pm\n I saw and examined the patient with Dr. , the ICU fellow, whose\n note reflects my input. I would add/emphasize: 81 y/o man with\n metastatic bladder cancer admitted with hydronephrosis, abdominal pain,\n and hypotension. The hypotension has been fluid-responsive. He\n tolerated the percutaneous nephrostomy procedure without apparent\n complications, and his abdominal pain has significantly improved. I\n doubt PE given low (vs. low-moderate) pre-test probably and a low-prob\n VQ scan. There is no clear evidence of infection at present, though we\n are following cultures. Will observe in ICU for now but likely ready\n for the floor later tonight or in a.m.\n ------ Protected Section Addendum Entered By: , MD\n on: 21:23 ------\n" }, { "category": "Physician ", "chartdate": "2146-08-15 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 338956, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 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 07:09 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\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///16/\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 12.7 g/dL\n 317 K/uL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\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": "2146-08-15 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 338957, "text": "Chief Complaint:\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation.\n On arrival to the ER he was afebrile, tachy to 103, tachypneic to\n 24, SBP in the high 90s, satting 90% on RA. Because of the abdominal\n pain and the CT findings, he was aggressively fluid resuscitated\n ended up getting five liters of fluid. RUQ U/S didn\nt reveal any acute\n findings. However, he was noted to have a positive UA with large blood,\n nitrite positive, 6-10 WBCs, 21-50 RBCs and many bacteria but LE\n negative. He had a peripheral leukocytosis of 16 and acute on chronic\n renal failure with a creatinine of 2.4 (baseline ~1.7). Urology\n recommended decompressing the hydronephrosis with IR assistance. He\n received empiric Vanc and Zosyn in the ER. He underwent the perc\n nephrostomy tube placement and was given a dose of Cipro in IR; he was\n then transferred to the MICU for further care.\n He currently is pain-free. He denies any intercurrent fevers, chills.\n He does endorse feeling fatigued and has been using a walker at home.\n He reports intermittent hematuria but no other urinary symptoms. No\n diarrhea, brbpr. .\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 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 07:09 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\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///16/\n Physical Examination\n Labs / Radiology\n 12.7 g/dL\n 317 K/uL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy today which is\n appropriate initial management of this presentation of ureteral\n compression. Will follow his creatinine and UOP. Urology to follow and\n assist with management of perc nephrostomy and his renal failure. Most\n likely his creatinine will improve with the aggressive volume\n resuscitation that he already received and decompression of the\n ureteral obstruction.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. It is not, however, unreasonable to continue antibiotic\n coverage for a urinary pathogen given that he was reportedly ill\n appearing on admission. I would, however, d/c Vanc and Zosyn given no\n e/o another infectious process at this time, especially since the\n gallbladder has been absolved based on the RUQ U/S. Would hold on\n triple lumen on this time. Follow cultures, WBC, temp, clinical status.\n 3) Pulmonary: He is ordered for a V/Q scan given that he was mildly\n hypoxic and tachycardic on admission. If indeterminate, then can pursue\n serial LENIs. Would not pursue CTA given his elevated creatinine.\n Clinical suspicion is moderate based on \n criteria.\n 4) F/E/N: Regular diet. Follow\nlytes, replete as needed. Would hold on\n further IVF at this time.\n 5) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\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": "2146-08-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 338971, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 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 07:26 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: 36\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///16/\n Physical Examination\n General: Awake and alert though mildly sleepy. NAD, pleasant,\n appropriate, cooperative.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in\n OP.\n Neck: Supple, no significant JVD or carotid bruits appreciated.\n Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi.\n Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: Trace edema, 2+ radial and DP pulses b/l\n Skin: No rashes or lesions noted.\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout. No nystagmus, dysarthria, intention or action tremor.\n 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle\n jerks bilaterally. Plantar response was flexor bilaterally.\n Labs / Radiology\n 317 K/uL\n 12.7 g/dL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81 yo male presenting with bladder cancer, found to have abd pain,\n tachycardia and borderline blood pressure, now s/p perc nephrostomy\n tube drainage of left hydronephrosis.\n #UTI: Treating with Cipro. Await culture results. WBC slightly\n decreased. Does not meet SIRS criteria.\n -pt has been aggressively volume repleted; will trend\n #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH\n approximately one week ago, further elevated on admission, still\n further increasing today. Some baseline renal dysfunction expected\n given pt's obstruction; suspect that acuity of further obstruction\n resulting in additional failure. Pt now s/p perc drainage placement and\n volume repletion. Check urine lytes and eos today. Continue to trend.\n #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic\n mets. Trend hepatic function and coagulation status closely.\n #Question PE: Initial concern for PE based on tachycardia and\n borderline oxygen saturation. Tachycardia has now improved; oxygen\n saturations remain slightly low. Overall clinical suspicion for PE is\n low and VQ scan interpreted as low probability.\n #Abd pain: Has resolved. Likely secondary to UTI, although numerous\n other etiologies are certainly possible. CT without evidence of acute\n process to explain pain. Plan to trend clinically with serial abd\n exams.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled\n Lines:\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PO diet\n Code status: full\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2146-08-15 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 338981, "text": "Chief Complaint:\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation. In ER, RUQ U/S didn\nt reveal any acute findings. Mildly\n positive UA with large blood, nitrite positive, 6-10 WBCs, 21-50 RBCs\n and many bacteria but LE negative. WBC16 and acute on chronic renal\n failure with a creatinine of 2.4 (baseline ~1.7). Urology recommended\n decompressing the hydronephrosis with IR assistance. He received\n empiric Vanc and Zosyn in the ER. Underwent perc nephrostomy tube\n placement and was given a dose of Cipro in IR; he was then transferred\n to the MICU for further care. Subsequently, abdominal pain somewhat\n improved.\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace 100mg \n Cipro 400mg IV Q24h\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/A.\n Flowsheet Data as of 07:09 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\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n V/Q scan low probability.\n Physical Examination\n General: Elderly, chronically ill appearing, using accessory muscles of\n respiration.\n HEENT: Anicteric. OP dry. Prominent sternocleidomastoids.\n CV: S1S2 SOFT HS\ns. No m/r/g\n Lungs: CTA bilaterally with bibasilar crackles ~ of the way up. No\n wheezing noted.\n Ab: Positive BS\ns. NT/ND today. Liver edge palpable below costal\n margin.\n Ext: No c/c/e.\n Neuro: Awake, alert, arousable, no focal deficits on exam.\n Labs / Radiology\n 12.7 g/dL\n 317 K/uL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy . Follow\n his creatinine and UOP. Urology to follow and assist with management of\n perc nephrostomy and his renal failure. His creatinine is increased\n today with adequate (although low-normal) UOP; the most likely\n pathology of his ARF likely remains hydronephrosis. Will continue to\n follow. If his creatinine continues to rise and/or his UOP decreases\n then he may need evaluation by the Renal service and consider for RRT.\n Consider renal U/S to re-evaluate his left hydronephrosis if his\n creatinine does not improve over the next day.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. Continuing Cipro to cover urine. Follow cultures, WBC, temp,\n clinical status.\n 3) Pulmonary: V/Q scan low , not pursue further PE w/u at this\n time. His oxygen saturation has been 90-95% on 2-4L NC. Unclear why he\n is hypoxic; it\ns possible that his COPD (radiographic evidence on\n outside chest CT) is contributing to this. Would add standing Albuterol\n and follow his oxygen saturations. Would check a TTE to assess cardiac\n function as well, especially in the setting of his aggressive volume\n resuscitation yesterday. Recheck CXR today.\n 4) Onc: Metastatic bladder cancer with possible secondary lung cancer\n (2cm spiculated LLL mass.) His prognosis with these processes is likely\n guarded from a long-term perspective. He and his family will need to be\n informed in real-time of his progress and prognosis as we gather more\n information.\n 5) F/E/N: Regular diet. Follow\nlytes, replete as needed.\n 6) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\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": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338909, "text": ".H/O back pain\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 339061, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL.\n Sepsis (with organ dysfunction)\n Assessment:\n Afebrile; VSS; C/O thirst, WBC count 16.2 (15.5 earlier today)\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; drinking adequate PO fluid.\n Plan:\n Cont to monitor I/O, VS, WBC..\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n Lt nephrostomy tube patent & in place. Flushing 10 cc Q 8 hrly.\n Response:\n Draining pinkish urine ; urine output adequate, pink, blood tinged\n urine.\n Plan:\n Will cont monitoring flushing nephrostomy tube Q8hrs.\n Activity intolerance.\n Assessment:\n C/O fatigueness.\n Action:\n OOB to chair with 3 assistance.\n Response:\n Tolerated well.\n Plan:\n Con activity as tolerated.\n Inadequate oxygenation\n Assessment:\n Titrating down O2 slowly . Desats initially to mid 70s for a brief\n pried. Denies SOB.\n Action:\n 2 L/min on flow now.\n Response:\n Satting at low 90\ns. Denies any SOB or resp distress.\n Plan:\n Will cont monitoring his Oxygenation, sat, SOB.\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 339040, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 339041, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL\n H/O back pain\n Assessment:\n Complaints of chronic, nagging back pain\n Action:\n Freq repositioning; administration of Tylenol x2\n Response:\n Was able to sleep intermittently; verbalized adequate pain control\n Plan:\n Cont with present treatment plan; oxycodone available for more intense\n pain\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Afebrile; VSS; complaints freq thirst\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; pt taking in good po\n Plan:\n I/O\ns; monitor fever; regular diet; prob call out to floor with\n suspicion of sepsis decreased\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n IR for left nephrostomy tube\n Response:\n Drained 45cc of blood tinged urine; u/o adequate overnight\n Plan:\n Offer po\ns; flush nephrostomy tube Q8hrs; emotional support; social\n service consult\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 338913, "text": "presumed COPD and recently diagnosed metastatic bladder CA with known\n left hydronephrosis presents from OSH ED after complaining of abd pain.\n The pt reports that he was in his usual state of health until mid-day\n on the day PTA. At that point, he noted the onset of RLQ abd pain that\n was non-radiating and intermittently sharp and dull. He presented to\n the ED at - where he was afebrile but noted to appear unwell\n and have an SBP in the 90s with associcated sinus tachycardia. A CT\n scan there demonstrated left hydronephrosis and a question of\n gallbladder distention.\n . An abd ultrasound was obtained.This study did not show gall bladder\n abdnormalities but did demonstrate extensive hepatic mets. He was given\n emperic doses of Zosyn and vancomycin as well as 5L NS. A urology\n consultation was obtained given the pt's hydronephrosis and a positive\n UA. There was a concern for left sided upper urinary tract infection\n and urgent percutaneous nephrostomy tube placement was advised; this\n was performed by IR immediately after the pt's arrival to the MICU. A\n VQ scan was also obtained given the pt's tachycardia and relative\n hypoxia; the results of this study are pending.\n .H/O back pain\n Assessment:\n Complaints of chronic, nagging back pain\n Action:\n Freq repositioning; administration of Tylenol x2\n Response:\n Was able to sleep intermittently; verbalized adequate pain control\n Plan:\n Cont with present treatment plan; oxycodone available for more intense\n pain\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Afebrile; VSS; complaints freq thirst\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; pt taking in good po\n Plan:\n I/O\ns; monitor fever; regular diet; prob call out to floor with\n suspicion of sepsis decreased\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n IR for left nephrostomy tube\n Response:\n Drained 45cc of blood tinged urine; u/o adequate overnight\n Plan:\n Offer po\ns; flush nephrostomy tube Q8hrs; emotional support; social\n service consult\n" }, { "category": "Physician ", "chartdate": "2146-08-15 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 339034, "text": "Chief Complaint:\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation. In ER, RUQ U/S didn\nt reveal any acute findings. Mildly\n positive UA with large blood, nitrite positive, 6-10 WBCs, 21-50 RBCs\n and many bacteria but LE negative. WBC16 and acute on chronic renal\n failure with a creatinine of 2.4 (baseline ~1.7). Urology recommended\n decompressing the hydronephrosis with IR assistance. He received\n empiric Vanc and Zosyn in the ER. Underwent perc nephrostomy tube\n placement and was given a dose of Cipro in IR; he was then transferred\n to the MICU for further care. Subsequently, abdominal pain somewhat\n improved.\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace 100mg \n Cipro 400mg IV Q24h\n Changes to medical and family history: PMH, SH, FH and ROS are\n unchanged from Admission except where noted above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems: N/A.\n Flowsheet Data as of 07:09 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\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n V/Q scan low probability.\n Physical Examination\n General: Elderly, chronically ill appearing, using accessory muscles of\n respiration though denies acute SOB.\n HEENT: Anicteric. OP dry. Prominent sternocleidomastoids.\n CV: S1S2 SOFT HS\ns. No m/r/g\n Lungs: Increased AP diameter; CTA bilaterally with bibasilar crackles\n ~ of the way up. No wheezing noted.\n Ab: Positive BS\ns. NT/ND today. Liver edge palpable below costal\n margin.\n Ext: No c/c/e.\n Neuro: Awake, alert, arousable, no focal deficits on exam.\n Labs / Radiology\n 12.7 g/dL\n 317 K/uL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy . Follow\n his creatinine and UOP. Urology to follow and assist with management of\n perc nephrostomy and his renal failure. His creatinine is increased\n today with adequate (although low-normal) UOP; the most likely\n pathology of his ARF likely remains hydronephrosis. Will continue to\n follow. If his creatinine continues to rise and/or his UOP decreases\n then he may need evaluation by the Renal service and consider for RRT.\n Consider renal U/S to re-evaluate his left hydronephrosis if his\n creatinine does not improve over the next day.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. Continuing Cipro to cover urine. Follow cultures, WBC, temp,\n clinical status.\n 3) Pulmonary: V/Q scan low , not pursue further PE w/u at this\n time. His oxygen saturation has been 90-95% on 2-4L NC. Unclear why he\n is hypoxic; it\ns possible that his COPD (radiographic evidence on\n outside chest CT) is contributing to this. Would add standing Albuterol\n and follow his oxygen saturations. Would check a TTE to assess cardiac\n function as well, especially in the setting of his aggressive volume\n resuscitation yesterday. Recheck CXR today.\n 4) Onc: Metastatic bladder cancer with possible secondary lung cancer\n (2cm spiculated LLL mass.) His prognosis with these processes is likely\n guarded from a long-term perspective. He and his family will need to be\n informed in real-time of his progress and prognosis as we gather more\n information.\n 5) F/E/N: Regular diet. Follow\nlytes, replete as needed.\n 6) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\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": "2146-08-15 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 339026, "text": "Chief Complaint:\n HPI:\n 81yo man with a h/o bladder cancer (metastatic, multiple recurrences,\n prior surgical management), tobacco use, possible COPD\n (radiographically diagnosed), who presents with ~36 hours of RLQ\n abdominal pain. Presented to where he was found to\n tachycardic to the 110s, SBP in the 90s and generally looked unwell.\n Ab/pelvic CT revealed the known large bladder bed mass with compression\n of the left ureter and left hydronephrosis. Ab CT also revealed some\n gallbladder distension. He was referred to the ER for further\n evaluation. In ER, RUQ U/S didn\nt reveal any acute findings. Mildly\n positive UA with large blood, nitrite positive, 6-10 WBCs, 21-50 RBCs\n and many bacteria but LE negative. WBC16 and acute on chronic renal\n failure with a creatinine of 2.4 (baseline ~1.7). Urology recommended\n decompressing the hydronephrosis with IR assistance. He received\n empiric Vanc and Zosyn in the ER. Underwent perc nephrostomy tube\n placement and was given a dose of Cipro in IR; he was then transferred\n to the MICU for further care. Subsequently, abdominal pain somewhat\n improved.\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace 100mg \n Cipro 400mg IV Q24h\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/A.\n Flowsheet Data as of 07:09 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\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n V/Q scan low probability.\n Physical Examination\n General: Elderly, chronically ill appearing, using accessory muscles of\n respiration though denies acute SOB.\n HEENT: Anicteric. OP dry. Prominent sternocleidomastoids.\n CV: S1S2 SOFT HS\ns. No m/r/g\n Lungs: Increased AP diameter; CTA bilaterally with bibasilar crackles\n ~ of the way up. No wheezing noted.\n Ab: Positive BS\ns. NT/ND today. Liver edge palpable below costal\n margin.\n Ext: No c/c/e.\n Neuro: Awake, alert, arousable, no focal deficits on exam.\n Labs / Radiology\n 12.7 g/dL\n 317 K/uL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81yo man with metastatic bladder cancer c/b bladder bed mass causing\n left ureteral obstruction with hydronephrosis and acute on chronic\n renal failure. s/p perc nephrostomy today and admitted to the MICU for\n further management.\n 1) Acute on chronic renal failure: S/p perc nephrostomy . Follow\n his creatinine and UOP. Urology to follow and assist with management of\n perc nephrostomy and his renal failure. His creatinine is increased\n today with adequate (although low-normal) UOP; the most likely\n pathology of his ARF likely remains hydronephrosis. Will continue to\n follow. If his creatinine continues to rise and/or his UOP decreases\n then he may need evaluation by the Renal service and consider for RRT.\n Consider renal U/S to re-evaluate his left hydronephrosis if his\n creatinine does not improve over the next day.\n 2) ID: Concern for UTI based on the initial UA; however, not markedly\n positive. Continuing Cipro to cover urine. Follow cultures, WBC, temp,\n clinical status.\n 3) Pulmonary: V/Q scan low , not pursue further PE w/u at this\n time. His oxygen saturation has been 90-95% on 2-4L NC. Unclear why he\n is hypoxic; it\ns possible that his COPD (radiographic evidence on\n outside chest CT) is contributing to this. Would add standing Albuterol\n and follow his oxygen saturations. Would check a TTE to assess cardiac\n function as well, especially in the setting of his aggressive volume\n resuscitation yesterday. Recheck CXR today.\n 4) Onc: Metastatic bladder cancer with possible secondary lung cancer\n (2cm spiculated LLL mass.) His prognosis with these processes is likely\n guarded from a long-term perspective. He and his family will need to be\n informed in real-time of his progress and prognosis as we gather more\n information.\n 5) F/E/N: Regular diet. Follow\nlytes, replete as needed.\n 6) Dispo: MICU; Access: pIV; Proph: SCDs, enteric feeds; Code: Full.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\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": "2146-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 339093, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL.\n Sepsis (with organ dysfunction)\n Assessment:\n Afebrile; VSS; C/O thirst, WBC count 16.2 (15.5 earlier today)\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; drinking adequate PO fluid.\n Plan:\n Cont to monitor I/O, VS, WBC..\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n Lt nephrostomy tube patent & in place. Flushing 10 cc Q 8 hrly.\n Response:\n Draining pinkish urine ; urine output adequate, pink, blood tinged\n urine.\n Plan:\n Will cont monitoring flushing nephrostomy tube Q8hrs.\n Activity intolerance.\n Assessment:\n C/O fatigueness.\n Action:\n OOB to chair with 3 assistance.\n Response:\n Tolerated well.\n Plan:\n Con activity as tolerated.\n Inadequate oxygenation\n Assessment:\n Titrating down O2 slowly . Desats initially to mid 70s for a brief\n pried. Denies SOB.\n Action:\n 2 L/min on flow now.\n Response:\n Satting at low 90\ns. Denies any SOB or resp distress.\n Plan:\n Will cont monitoring his Oxygenation, sat, SOB.\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 339094, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL.\n Sepsis (with organ dysfunction)\n Assessment:\n Afebrile; VSS; C/O thirst, WBC count 16.2 (15.5 earlier today)\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; drinking adequate PO fluid.\n Plan:\n Cont to monitor I/O, VS, WBC..\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n Lt nephrostomy tube patent & in place. Flushing 10 cc Q 8 hrly.\n Response:\n Draining pinkish urine ; urine output adequate, pink, blood tinged\n urine.\n Plan:\n Will cont monitoring flushing nephrostomy tube Q8hrs.\n Activity intolerance.\n Assessment:\n C/O fatigueness.\n Action:\n OOB to chair with 3 assistance.\n Response:\n Tolerated well.\n Plan:\n Con activity as tolerated.\n Inadequate oxygenation\n Assessment:\n Titrating down O2 slowly . Desats initially to mid 70s for a brief\n pried. Denies SOB.\n Action:\n 2 L/min on flow now.\n Response:\n Satting at low 90\ns. Denies any SOB or resp distress.\n Plan:\n Will cont monitoring his Oxygenation, sat, SOB.\n" }, { "category": "Nursing", "chartdate": "2146-08-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 339107, "text": "81yo c recent dx met bladder ca presented to OSH w/ abd pain x 2wks,\n weakness, pain RLQ, N/V. 3days prior abd CT which revealled\n hydronephrosis. Presented to Nedham anuric ^ BUN, Creat ,\n transferred to ED ARF /urology service for metastatic bladder\n cancer c/b bladder bed mass causing left ureteral obstruction with\n hydronephrosis and acute on chronic renal failure. Upon arrival was\n found to be hypoxic on R/A sat 80% tachypneic, tachycardic,\n hypotensive SBP 90, afebrile. Foley placed for scant dk brown urine,\n recieved 5L NS, lactale 2.5, WBC 14, pan cultured blood,urine,, VQ scan\n r/o PE ( neg), abd CT revealled obstructing Bladder tumor. Recieved abx\n vancomycin/Zosyn, recieved Morphine 2mg IV x2 for pain. Admitted to\n MICU for urosepsis and further management.\n PMH:\n Bladder cancer diagnosed in s/p surgery x 2, BCG therapy in .\n Recurrence again in with extensive metastases (liver, left femur\n and bladder bed mass compressing left ureter.) Recently evaluated by\n Med Onc.\n Distant left inguinal hernia repair.\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL.\n Sepsis (with organ dysfunction)\n Assessment:\n Afebrile; VSS; C/O thirst, WBC count 16.2 (15.5 earlier today)\n Action:\n Freq monitoring of VS and I/O\n Response:\n No further fluid boluses indicated; drinking adequate PO fluid.\n Plan:\n Cont to monitor I/O, VS, WBC..\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Bladder CA dx 05 with recently dx liver mets with LLL mass; bladder\n tumor causing obstruction\n Action:\n Lt nephrostomy tube patent & in place. Flushing 10 cc Q 8 hrly.\n Response:\n Draining pinkish urine ; urine output adequate, pink, blood tinged\n urine.\n Plan:\n Will cont monitoring flushing nephrostomy tube Q8hrs.\n Activity intolerance.\n Assessment:\n C/O fatigueness.\n Action:\n OOB to chair with 3 assistance.\n Response:\n Tolerated well.\n Plan:\n Con activity as tolerated.\n Inadequate oxygenation\n Assessment:\n Titrating down O2 slowly . Desats initially to mid 70s for a brief\n pried. Denies SOB.\n Action:\n 2 L/min on flow now.\n Response:\n Satting at low 90\ns. Denies any SOB or resp distress.\n Plan:\n Will cont monitoring his Oxygenation, sat, SOB.\n PNEUMOCOCCAL VACCINE TO BE GIVEN BEFORE DISCHARGE.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 78.9 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Unknown;\n Precautions:\n PMH: COPD, Smoker\n CV-PMH:\n Additional history: Bladder cancer diagnosed in s/p surgery x 2,\n BCG therapy in . Recurrence again in with extensive metastases\n (liver, left femur and bladder bed mass compressing left ureter.)\n Recently evaluated by Med Onc.\n Distant left inguinal hernia repair. Met lung\n nephrolithiasis in distant past. 2 cm speculated mass in superior\n segment of LL\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:66\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 90 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,165 mL\n 24h total out:\n 1,055 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:44 PM\n Potassium:\n 5.4 mEq/L\n 02:44 PM\n Chloride:\n 104 mEq/L\n 02:44 PM\n CO2:\n 15 mEq/L\n 02:44 PM\n BUN:\n 87 mg/dL\n 02:44 PM\n Creatinine:\n 3.2 mg/dL\n 02:44 PM\n Glucose:\n 88 mg/dL\n 02:44 PM\n Hematocrit:\n 39.4 %\n 02:44 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 7\n Transferred to: F212\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2146-08-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 338982, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS DRAIN INSERTION - At 10:15 AM\n L nephrostomy tube placed\n URINE CULTURE - At 11:09 AM\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:15 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 07:26 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: 36\nC (96.8\n HR: 84 (77 - 92) bpm\n BP: 117/70(82) {91/37(53) - 123/72(82)} mmHg\n RR: 22 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 6,314 mL\n 340 mL\n PO:\n 990 mL\n 340 mL\n TF:\n IVF:\n 324 mL\n Blood products:\n Total out:\n 703 mL\n 225 mL\n Urine:\n 653 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,611 mL\n 115 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///16/\n Physical Examination\n General: Awake and alert though mildly sleepy. NAD, pleasant,\n appropriate, cooperative.\n HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in\n OP.\n Neck: Supple, no significant JVD or carotid bruits appreciated.\n Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi.\n Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: Trace edema, 2+ radial and DP pulses b/l\n Skin: No rashes or lesions noted.\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout. No nystagmus, dysarthria, intention or action tremor.\n 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle\n jerks bilaterally. Plantar response was flexor bilaterally.\n Labs / Radiology\n 317 K/uL\n 12.7 g/dL\n 105 mg/dL\n 3.0 mg/dL\n 16 mEq/L\n 5.1 mEq/L\n 82 mg/dL\n 107 mEq/L\n 137 mEq/L\n 37.0 %\n 15.5 K/uL\n [image002.jpg]\n 04:30 AM\n WBC\n 15.5\n Hct\n 37.0\n Plt\n 317\n Cr\n 3.0\n Glucose\n 105\n Other labs: PT / PTT / INR:14.2/24.9/1.2, ALT / AST:154/440, Alk Phos /\n T Bili:541/2.8, LDH:9840 IU/L, Ca++:8.0 mg/dL, Mg++:2.8 mg/dL, PO4:5.0\n mg/dL\n Assessment and Plan\n 81 yo male presenting with bladder cancer, found to have abd pain,\n tachycardia and borderline blood pressure, now s/p perc nephrostomy\n tube drainage of left hydronephrosis.\n #UTI: Treating with Cipro. Await culture results. WBC slightly\n decreased. Does not meet SIRS criteria.\n -pt has been aggressively volume repleted; will trend\n #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH\n approximately one week ago, further elevated on admission, still\n further increasing today. Some baseline renal dysfunction expected\n given pt's obstruction; suspect that acuity of further obstruction\n resulting in additional failure. Pt now s/p perc drainage placement and\n volume repletion. Check urine lytes and eos today. Continue to trend.\n Consider renal US if no improvement. Check PM chem panel.\n #SOB/question COPD: Pt with extensive smoking history and a question of\n COPD based on prior imaging. No has crackles on exam after 5L volume\n resuscitation. Will check CXR and echo today. Start standing albuterol\n and ipratropium.\n #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic\n mets. Trend hepatic function and coagulation status closely.\n #Question PE: Initial concern for PE based on tachycardia and\n borderline oxygen saturation. Tachycardia has now improved; oxygen\n saturations remain slightly low. Overall clinical suspicion for PE is\n low and VQ scan interpreted as low probability.\n #Abd pain: Has resolved. Likely secondary to UTI, although numerous\n other etiologies are certainly possible. CT without evidence of acute\n process to explain pain. Plan to trend clinically with serial abd\n exams.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled\n Lines:\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PO diet\n Code status: full\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2146-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031449, "text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for evidence of PNA, CHF, COPD\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with suspected COPD and low O2 sats, s/p 5L fluid repletion\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of PNA, CHF, COPD\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 12:33 PM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: COPD, O2 sat.\n\n One portable view. Comparison with . The lungs remain clear except\n for minimal streaky density at the lung bases consistent with subsegmental\n atelectasis or scarring. The heart is normal in size. The aorta is tortuous.\n Mediastinal structures are otherwise unremarkable. The bony thorax is grossly\n intact. There is no significant interval change.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-08-14 00:00:00.000", "description": "LUNG SCAN", "row_id": 1031283, "text": "LUNG SCAN Clip # \n Reason: 81 Y/O MALE WITH TACHYCARDIA, HYPOXIA AND KNOWN CA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 5.2 mCi Tc-m MAA ();\n 43.4 mCi Tc-99m DTPA Aerosol ();\n HISTORY: 81 year old male with metastatis bladder carcinoma, presenting with\n hypoxia and tachycardia.\n\n INTERPRETATION: Ventilation images obtained with Tc-m aerosol in 6 views\n demonstrate diminished irregular pattern of uptake with central tracer clumping.\n There is a relatively larger area of abnormal ventilation at the right apex.\n\n Perfusion images in the same 8 views show a small matched defects in both lungs.\n There is a relatively larger defect in the right apex which matches the\n ventilatory abnormality.\n\n Chest x-ray shows plate-like atelectasis at the left lung base.\n\n IMPRESSION: Matched ventilation / perfusion defects. Low likelihood ratio for\n recent pulmonary embolism.\n\n\n , M.D.\n , M.D. Approved: WED 3:25 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": "2146-08-16 00:00:00.000", "description": "RENAL U.S.", "row_id": 1031570, "text": " 8:59 AM\n RENAL U.S. Clip # \n Reason: eval for resolution of hydronephrosis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with met bladder CA, admitted with L hydronephrosis, now s/p L\n nephrostomy but with increasing Creatinine\n REASON FOR THIS EXAMINATION:\n eval for resolution of hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd TUE 12:07 PM\n Resolution of hydronephrosis in the left kidney. Multiple solid masses in the\n left kidney, worrisome for metastatic disease. Mild ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with metastatic bladder cancer admitted with left\n hydronephrosis. Now status post left nephrostomy but with increasing\n creatinine. Evaluate for resolution of hydronephrosis.\n\n COMPARISON: Abdomen and pelvic CT of .\n\n TECHNIQUE: Renal ultrasound.\n\n FINDINGS: The liver is heterogeneous in appearance consistent with diffuse\n metastatic disease. There is mild ascites. The right kidney measures 12.8 cm\n without any evidence of hydronephrosis or definite masses seen. The left\n kidney measures 11.3 cm. Since prior CT, there has been resolution of\n hydronephrosis of the left kidney. Multiple solid masses, some exophytic, are\n seen within the left kidney, mainly in the upper and mid portions. These are\n worrisome for metastatic disease.\n\n The bladder is empty and cannot be assessed.\n\n IMPRESSION:\n 1. Resolution of hydronephrosis in the left kidney.\n 2. Multiple solid masses seen in the left kidney, worrisome for metastatic\n disease.\n 3. Diffuse metastatic hepatic disease.\n 4. Mild ascites.\n\n Findings discussed with Dr. at 11 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2146-08-16 00:00:00.000", "description": "RENAL U.S.", "row_id": 1031571, "text": ", L. MED FA2 8:59 AM\n RENAL U.S. Clip # \n Reason: eval for resolution of hydronephrosis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with met bladder CA, admitted with L hydronephrosis, now s/p L\n nephrostomy but with increasing Creatinine\n REASON FOR THIS EXAMINATION:\n eval for resolution of hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n Resolution of hydronephrosis in the left kidney. Multiple solid masses in the\n left kidney, worrisome for metastatic disease. Mild ascites.\n\n" }, { "category": "Radiology", "chartdate": "2146-08-14 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1031273, "text": " 5:01 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval ductal anatomy for ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n cholangitis\n REASON FOR THIS EXAMINATION:\n eval ductal anatomy for ERCP\n ______________________________________________________________________________\n WET READ: RSRc SUN 6:26 AM\n No evidence cholecystitis. Numerous hepatic metastases; mildly distended\n gallbladder but no intrahepatic biliary dilatation and CBD normal in size.\n Trace ascites.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old male with cholangitis. Please evaluate ductal anatomy\n for ERCP.\n\n COMPARISON: Concurrent outside CT abdomen and pelvis.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates innumerable hepatic\n metastases from known bladder cancer. A few shadowing gallstones are\n identified. There is trace ascites. The pancreas is not well visualized\n secondary to bowel gas. The main portal vein is patent, with antegrade flow.\n\n IMPRESSION:\n 1. Innumerable hepatic metastases from bladder cancer.\n 2. Cholelithiasis without evidence of cholecystitis.\n 3. No evidence of intrahepatic biliary ductal dilatation; normal size of CBD.\n\n Findings posted to ED dashboard at the time the scan was completed.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-08-14 00:00:00.000", "description": "INTRO CATH RENAL PELVIS FOR DRAINAGE", "row_id": 1031304, "text": " 10:24 AM\n PERC NEPHROSTO Clip # \n Reason: please place perc drain\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with bladder CA, sepsis and L hydronephrosis. Needs perc\n drainage per urology\n REASON FOR THIS EXAMINATION:\n please place perc drain\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd SUN 12:24 PM\n 8 French nephrostomy tube placed into the left renal pelvis and attached to\n drainage bag.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 81-year-old man with bladder cancer, severe left\n hydroureter, and moderate to severe left hydronephrosis. There is clinical\n suspicion of sepsis. Request is made for percutaneous nephrostomy catheter\n placement.\n\n OPERATORS: Dr. and Dr. who was the attending\n physician and present for the entire procedure.\n\n FLUOROSCOPY TIME: One minute.\n\n MEDICATIONS:. Moderate sedation was provided by administering divided doses\n of a total of 50 mcg of fentanyl and 0.5 mg of Versed throughout the total\n intraservice time of 15 minutes during which the patient's hemodynamic\n parameters were continuously monitored.\n\n PROCEDURE: After review of the risks and benefits of the procedure as well as\n conscious sedation, informed consent was obtained. The patient was brought to\n the angiography suite and placed prone on the imaging table. The left\n posterior abdominal wall was prepped and draped in the usual sterile fashion.\n Ultrasound evaluation demonstrated a severely hydronephrotic left kidney. A\n mid kidney calix was selected for targeting. Under ultrasound guidance, a\n micropuncture needle was advanced into this calix until there was urine\n return. A 0.018 wire was passed through the needle into the collecting\n system. A small skin incision was made over the needle and the needle was\n removed and replaced with the Accustick system. The 5 French catheter of the\n Accustick system was advanced into the collecting system. Injection of\n contrast demonstrated filling of the renal pelvis and flow of contrast into\n the proximal ureter.\n\n Next, a super stiff Amplatz wire was advanced through the sheath into the\n collecting system and the sheath was removed. A new 8 French nephrostomy tube\n was advanced over the wire and coiled in the renal pelvis. It was attached to\n (Over)\n\n 10:24 AM\n PERC NEPHROSTO Clip # \n Reason: please place perc drain\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n a drainage bag and sutured to the skin. A sterile dressing was applied. There\n were no immediate complications.\n\n IMPRESSION:\n 1. Ultrasound and fluoroscopic evaluation demonstrating a severely\n hydronephrotic left-sided collecting system.\n 2. Placement of 8 French nephrostomy catheter with locking loop formed in the\n renal pelvis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-08-14 00:00:00.000", "description": "INTRO CATH RENAL PELVIS FOR DRAINAGE", "row_id": 1031305, "text": ", F. MED MICU-7 10:24 AM\n PERC NEPHROSTO Clip # \n Reason: please place perc drain\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with bladder CA, sepsis and L hydronephrosis. Needs perc\n drainage per urology\n REASON FOR THIS EXAMINATION:\n please place perc drain\n ______________________________________________________________________________\n PFI REPORT\n 8 French nephrostomy tube placed into the left renal pelvis and attached to\n drainage bag.\n\n" }, { "category": "Radiology", "chartdate": "2146-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031450, "text": ", F. MED MICU-7 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for evidence of PNA, CHF, COPD\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with suspected COPD and low O2 sats, s/p 5L fluid repletion\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of PNA, CHF, COPD\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031229, "text": " 12:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with low O2 sat and productive cough\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old male with low oxygen saturation and productive cough.\n Please evaluate for acute process.\n\n COMPARISON: None available.\n\n SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is\n normal. The heart is not enlarged. There is linear platelike atelectasis at\n the left lung base. The lungs are otherwise clear. Osseous structures are\n unremarkable.\n\n IMPRESSION: No evidence of focal consolidation on this single view.\n\n" }, { "category": "Radiology", "chartdate": "2146-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031725, "text": " 9:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with COPD and metastatic renal cell with acute SOB, hypoxia and\n increased work of breathing\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic renal cell carcinoma with shortness of breath.\n\n FINDINGS: In comparison with study of , there is continued elevation of\n the right hemidiaphragm with atelectatic changes at the bases. No evidence of\n acute focal pneumonia.\n\n\n" }, { "category": "Echo", "chartdate": "2146-08-16 00:00:00.000", "description": "Report", "row_id": 87792, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 107/70\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 15:21\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\nLEFT VENTRICLE: Small LV cavity. Suboptimal technical quality, a focal LV wall\nmotion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal 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.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity is unusually\nsmall. Due to suboptimal technical quality, a focal wall motion abnormality\ncannot be fully excluded. Left and right ventricular systolic function appears\ngrossly preserved but views are technically suboptimal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is a trivial/physiologic pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2146-08-14 00:00:00.000", "description": "Report", "row_id": 222865, "text": "Sinus tachycardia. Low voltage. Left axis deviation. Left anterior\nfascicular block. Right bundle-branch block. Consider inferior myocardial\ninfarction. ST-T wave abnormalities. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2105-08-24 00:00:00.000", "description": "Report", "row_id": 1562062, "text": "T/SICU NPN Transfer Note\nBrief \n Pt. is awake and appropriate. Very sleepy earlier this shift with phenergan dose(nausea), easily arousable now. MAE. Has gd strength in all 4 extremities, cooperates with exam. C/O neck pain when questioned. J collar remains on. Pt. is ordered for a neck MRI, prob tomorrow as she was too sleepy for exam to remove collar today. PERL. Went for CT of her head today during day shift, essentially unchanged. Sml amt of bldy drg(old) from left ear.\n\nCV- Stable BP and HR, Sinus tac, no ectopy. Skin warm and dry, easily palpable periph pulses.\n\nResp- Adequate sats on rm air.\n\nEndo- FS BS not requiring coverage.\n\nID- Tmax yesterday, 103.7 No antibiotics ordered. Afeb now.\n\nGI- Abd flat, soft and non-tender. Pt. has had 2 episodes of nauseaand emesis, last episode she got phenergan with gd relief.\n\nGU- Adequate u/o via foley.\n\nInteg- Skin intact except for abt 3 sml abrasions over back, otherwise intact.\n\nA: 19 yr female s/p trauma, fall down several stairs. Sustained 2 sml subdural bleeds, left side. Intubated over night, extubated yesterday and doing well with unchanged head CT scan. Awake and appropriate. Emesis today relieved with phenergan.\n\nP: Transfer pt. to floor. Monitor neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-23 00:00:00.000", "description": "Report", "row_id": 1562059, "text": "Respiratory Care:\nPt extubated to a 40% cool neb. O2 Sat = 100%\nrr = 14 hr = 123 BP = 132/32\n" }, { "category": "Nursing/other", "chartdate": "2105-08-23 00:00:00.000", "description": "Report", "row_id": 1562060, "text": "T-SICU Nsg note\n Pt transferred from outside hospital by Med Flight. Pt fell down several stairs, hitting head with loss of consciousness briefly, bleeding from L ear. boyfriend, who was with pt at time of fall transported pt to hospital in his car. PT initially alert & oriented. CT at hospital ? of epidural bleed. Pt became lethargic and intubated, then Med-Flighted here. Repeat CT scans here show small subdural bleeds and L temporal contusion. Pt sedated on propofol. Serosanguinous drainage from L ear.\n Pt arouses to voice, nods to questions, follows commands, able to lift and hold arms & legs. Cough & gag reflexes intact, pupils react briskly. C/o headache - when asked if having pain nods head yes.\n Lungs clear, strong cough, scant sputum. Pt weaned to PSV with good RSBI and extubated about 1700.\n PT continues drowsy, only responds when spoken to and sometime requires touch or trapezius squeeze to answer. Ox3, c/o sore throat and hurts to talk. Follows commands.\n Brisk u/o. NS at 60cc/hr. Dilantin load given. OG with dk red drainage. OG removed just prior to extubation.\n Pt's parents and SO, and sisters and other family & friends in to visit and supportive of pt & each other. Pt's parents spoke to Neuro team about plan.\nA: extubated, pt remains quite lethargic. Oriented and follows commands.\nP: continue to assess neuro status q 2 hrs. Informational & emotional support to pt & family. Plan for CT of head tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2105-08-24 00:00:00.000", "description": "Report", "row_id": 1562061, "text": "T-SICU\n1900-0700\n\n\nNEURO: Pt lethargic and oriented x 3, improving during shift not as lethargic as in the beginning of shift. Pupils equal with brisk reaction , to command with decreased strength, grips and push/pull equal able to lift all extremities off bed. will help with turning. -j collar remain in place. pt c/o neck pain during exam.\n\nCV: HR 110-130's with period of PVC's. repleted with 2 grams Mag Sulfate x 2. no PVC's since. elevated temp at the same time 103.7. tylenol 650mg given PR. BP stable 120-150's. INR elevated Vitamin K+ 10mg given po and one unit FFP given. Dilantin level elevated and dose decreased. one 500cc LR bolus given. Blood cultures x 2 done and U/A sent.\n\nRESP: pt extubated around 1700 on . pt on room air. O2 sats 93-95%. pt has fair cough effort nonproductive.\n\nGU/GI: abd soft with hypoactive bowel sounds. no BM this shift. Foley cath with good urine output hourly clear yellow urine.\n\nSKIN: multi abrasions noted to back and posterior hips.\n\nENDO: glucose fingersticks 115 and 121. tx per sliding scale.\n\nENT: L ear with old blood noted. ENT dr in and elevaluated pt. ear drops ordered.\n\nPLAN: possible tx to floor today.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-23 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 882638, "text": " 5:04 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n COMPARISONS: No comparisons are available.\n\n SINGLE VIEW OF THE CHEST: The heart is of normal size. The mediastinal and\n hilar contours are within normal limits. The pulmonary vasculature is normal.\n The lung fields are clear. There are no pleural effusions or focal\n consolidations. The osseous structures are unremarkable. There is an NG tube\n with the tip in the stomach. The ET tube tip is located approximately 3 cm\n from the carina.\n\n AP SINGLE VIEW OF THE PELVIS: No definite fracture is identified. The pubic\n symphysis and SI joints are within normal limits. The hip joints are in\n normal position.\n\n IMPRESSION: No evidence of significant injury to the chest or pelvis in these\n radiographs.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 882639, "text": " 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FELL DOWN A FLIGHT OF STAIRS.R/O BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with fall & head bleed\n REASON FOR THIS EXAMINATION:\n ICH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SUN 5:52 AM\n Left frontoparietal 3mm subdural.\n Left temporal extraaxial hemorrhage, possibly representing 6mm epidural.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female status post fall. Question intracranial\n hemorrhage.\n\n COMPARISONS: Comparison is made to CT performed in an outside hospital on the\n same day at approximately 2:30 a.m.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: There is a small, 3 mm left frontotemporal subdural hemorrhage. In\n the temporal region, there is another area of hemorrhage measuring\n approximately 6 mm, which is suspicious for an epidural (series 2A, image 12).\n Another area of hemorrhage seen on series 2A, image 10 likely represents a\n contusion of the lateral left temporal lobe. A mild degree of subarachnoid\n hemorrhage is present on the left as well. There is no shift of normally\n midline structures. No evidence of hydrocephalus or major vascular territorial\n infarction is identified.\n Examination of the bone windows demonstrates postoperative changes of left\n mastoidectomy and probable resection of the ossicles, which cannot be\n identified. No definite fractures were seen in these images.\n\n IMPRESSION: Multiple extraaxial small hemorrhages as described above. Left\n temporal lobe contusion. Continued follow-up is recommended.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2105-08-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 882640, "text": " 5:28 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: FALL.R/O FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with fall & head bleed\n REASON FOR THIS EXAMINATION:\n fx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SUN 6:03 AM\n no c-spine fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female status post fall.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: CT of the cervical spine without IV contrast. Sagittal and\n coronal reformations were performed.\n\n FINDINGS: The vertebral bodies are of normal height. The alignment of the\n vertebral bodies is anatomic. The patient is intubated. No fractures are\n seen. The visualized outline of the thecal sac is preserved. There is\n incomplete fusion of the posterior arch of C1, which is most likely a\n congenital abnormality since this is well corticated. The facet joints are in\n line. C1 and C2 alignment is unremarkable. The dens is intact. The\n visualized portions of the thyroid are unremarkable. The lung apices are\n clear. Please refer to CT of the temporal bones for details. There is\n mucosal thickening of the maxillary sinus. There is a small amount of fluid\n in the right maxillary sinus.\n\n IMPRESSION:\n 1. No evidence of fracture.\n\n 2. Fluid in the external auditory canal could represent blood. Please review\n the report of the CT of the temporal bones for more details.\n\n Please review the report of head CT for details on the temporal extra-axial\n hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 882641, "text": " 5:29 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE\n Reason: FELL DOWN STAIRS.R/O INTERNAL INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with fall & head bleed\n REASON FOR THIS EXAMINATION:\n contusion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SUN 6:08 AM\n No evidence of injury to chest or abdomen.\n\n Likely ADPKD.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female with fall. The patient is unconscious and has\n had hemorrhage.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. 150 cc of\n Optiray 350 were administered. Nonionic IV contrast was used due to rapid\n bolus necessary for this study.\n\n Multiplanar reconstructions were performed.\n\n CT OF THE CHEST WITH IV CONTRAST: There are multiple small left axillary\n lymph nodes that do not meet CT criteria for pathology. The largest one\n measures 8 mm. There are no significant mediastinal or hilar lymph nodes. The\n aorta is intact without evidence of aortic injury. There is no pericardial\n effusion. The heart and great vessels are otherwise unremarkable. There is no\n evidence of pneumothorax. There are minimal dependent changes in the left\n lung. There are no pleural effusions or focal consolidations. There are\n dependent changes in the lungs. The airway is patent to level of subsegmental\n bronchi. There is an NG tube with the tip in the stomach. The liver, spleen,\n adrenal glands, and visualized loops of small and large bowel are\n unremarkable. There is no free fluid or free air in the abdomen. There are\n multiple cysts in the kidneys bilaterally, suggestive of early polycystic\n kidney disease.\n\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There is a Foley catheter within\n the urinary bladder. There is a tiny amount of free fluid in the pelvis in\n the physiologic range. Uterus and adnexa are within normal limits. The\n intrapelvic bowel loops are normal.\n\n BONE WINDOWS: There is no evidence of fractures.\n\n MULTIPLANAR RECONSTRUCTIONS: Were important to exclude fractures of the\n thoracic or lumbar spine.\n (Over)\n\n 5:29 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE\n Reason: FELL DOWN STAIRS.R/O INTERNAL INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No significant injury to the chest or abdomen/pelvis.\n 2. Findings consistent with polycystic kidney disease.\n 3. Minimal patchy opacities in the left lung most likely represent dependent\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-23 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 882642, "text": " 5:42 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please assess temporal bones, possible CSF leak.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman s/p fall with ?ruptured left TMs.\n REASON FOR THIS EXAMINATION:\n Please assess temporal bones, possible CSF leak.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SUN 6:18 AM\n Minimally displaced fracture of the squamous portion of the left temporal\n bone.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Trauma with hemorrhages.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: Multiple thin-cut axial images of the temporal bones were obtained\n without IV contrast. Coronal and sagittal reformations were performed.\n\n No IV contrast was used.\n\n FINDINGS: The patient is status post left mastoidectomy. There is also\n possible resection of the middle ear structures, since the ossicles in the\n left middle ear cannot be seen. There is soft tissue density within the left\n middle ear and external auditory canal. The right external auditory canal is\n aerated, and the right tympanum and middle ear and ossicles are within normal\n limits. But there is soft tissue or fluid in the suprior epitympanic cavity\n and the mastoid air cells on the right. The tegmen tympani is thinned and\n appears perforated. These findings should be correlated with what is know\n about the patient's mastoid/temporal bone abnormalities, as this does not\n appear to be an acute problem.\n\n There is minimally displaced fracture of the squamous portion of the inferior\n left temporal bone, which is best seen on series 200B, image 33 or series 2,\n image 64. This extends through the posterior margin or the left mastoidectomy\n defect. No other fractures were identified.\n\n There is mucosal thickening in bilateral maxillary sinuses with a small amount\n of fluid in the right maxillary sinus. The other paranasal sinuses are\n normally aerated. The orbits are intact. Please refer to the CT of the head\n for description of the extra- axial hemorrhages. Again, noted is incomplete\n fusion of the posterior arch of C1.\n\n IMPRESSION:\n 1. Minimally displaced fracture of the squamous portion of the left temporal\n bone as described above.\n 2. Opacification, possibly blood, within the left external auditory canal and\n middle ear. Extensive postoperative changes of left mastoidectomy and likely\n resection of middle ear structures.\n (Over)\n\n 5:42 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please assess temporal bones, possible CSF leak.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n 3. Right mastoid and epitympanic cavity opacity and perhaps tegmen tympani\n abnormality.\n 4. Mucosal thickening and fluid in the sinuses as described above.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2105-08-26 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 883003, "text": " 10:20 AM\n MR CERVICAL SPINE Clip # \n Reason: evidence of ligamentous injury?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with posterior cervical tenderness s/p MVC and equivical\n flex/ex c-spine films\n REASON FOR THIS EXAMINATION:\n evidence of ligamentous injury?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Posterior cervical tenderness and some anterior\n displacement of C3 relative to and of C4 relative to with flexion.\n\n TECHNIQUE: Sagittal T1-weighted, T2-weighted and STIR images and axial\n T2-weighted and gradient echo images were obtained.\n\n FINDINGS:\n\n No bone marrow or ligamentous edema is seen to suggest a fracture or\n ligamentous injury. The vertebral bodies are normally aligned when the\n patient is positioned for MRI. No disc herniation is seen. The canal and\n neural foramina are well maintained. The spinal cord and craniovertebral\n junction appear normal.\n\n IMPRESSION: Normal MRI of the cervical spine.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-08-25 00:00:00.000", "description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS", "row_id": 882907, "text": " 11:40 AM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: Need flexion/extension views of cervical spine to r/o fractu\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with s/p fall down stairs; persistent posterior neck pain\n REASON FOR THIS EXAMINATION:\n Need flexion/extension views of cervical spine to r/o fracture or other\n processes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall and posterior neck pain.\n\n CERVICAL SPINE, TWO VIEWS DURING FLEXION AND EXTENSION: No prior studies are\n available for comparison. C1 through C7 are imaged. There is approximately 2\n mm of anterolisthesis of C3 with respect to C4 and C4 with respect to C5\n during the flexion maneuver which corrects during the extension maneuver.\n Normal vertebral body alignment is otherwise preserved. Vertebral body\n heights and intervertebral disc spaces appear normal. Prevertebral soft\n tissues are within normal limits.\n\n IMPRESSION: Minimal anterolisthesis of C3 with respect to C4 and C4 with\n respect to C5, which corrects during the extension maneuver.\n\n" }, { "category": "Radiology", "chartdate": "2105-08-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 882753, "text": " 9:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n NONCONTRAST HEAD CT SCAN\n\n HISTORY: Followup study for previously diagnosed multiple subdural\n hemorrhages and subarachnoid hemorrhage.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: The study is degraded to a moderate degree by motion artifacts.\n Allowing for this limitation, there is no significant interval change in the\n size or configuration of the small left cerebral convexity acute subdural\n hemorrhages. At this time, it is somewhat difficult to appreciate the\n suspected left temporal lobe contusion, perhaps due to the presence of\n overlying streak artifacts. At this time, as well, it is difficult to detect\n subarachnoid hemorrhage. There is no hydrocephalus or shift of normally\n midline structures.\n\n Once again, there is a left mastoidectomy defect. Please secure history\n regarding the underlying pathology that prompted this surgical procedure\n (unusual for a patient of this age). There is no other definite interval\n change seen aside from slightly more mucosal thickening along the right\n lateral wall of the right sphenoid sinus air cell.\n\n CONCLUSION: Stable appearance of small left cerebral convexity subdural\n hemorrhages. Please see above report for additional discussion.\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2151-06-13 00:00:00.000", "description": "Report", "row_id": 313563, "text": "Sinus tachycardia. Intra-atrial conduction delay. Modest left axis deviation\nmay be due to left anterior fascicular block, although is non-diagnostic.\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy.\nDelayed R wave progression with late precordial QRS transition is\nnon-diagnostic but clinical correlation is suggested. Since the previous\ntracing of sinus tachycardia is now present, delayed R wave progression\nwith late precordial QRS transition is more prominent and precordial lead\nQRS voltage is also more prominent.\n\n" }, { "category": "ECG", "chartdate": "2151-06-14 00:00:00.000", "description": "Report", "row_id": 313562, "text": "Regular narrow complex tachy-arrhythmia of uncertain mechanism. Modest left\naxis deviation may be due to left anterior fascicular block. Low limb lead\nQRS voltage is non-specific. Prominent precordial lead QRS voltage suggests\nleft ventricular hypertrophy. Delayed R wave progression with late precordial\nQRS transition. Modest ST-T wave changes. findings are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of tachycardia rate\nis faster.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2176-07-19 00:00:00.000", "description": "Report", "row_id": 1535628, "text": "CCU NPN ADMIT\nS: \" I feel good now \"\nO: 77 yo male transferred from hosp. with Ant. MI for cath/intervention.\n\nPMH: HTN, anemia. quit smoking 18yrs ago. CVA ', minimal right residual\nALLERGIES: sulfa, PCN, ? ASA\n\nSOCIAL: married x57yrs. 6 children. retired , but works now 40hr/\n wk. at \n\nHPI: developed CP while at work, assoc. with nausea and diaphoresis. co-worker drove him home where he took SL ntg without relief. EMT's called to hosp. ST elevations noted V2-6 and II,III,F. Rx with heparin, TNG, morphine, lasix, lopressor. brought to for cath.\n\nCATH: arrived to cath painfree on 60mcq TNG and heparin. hep. d/c'd for cath. mLAD 100%->stentx1 to 60% with TIMI 3 flow.\n also RCA 60%\nsome CP at end of case but painfree on arrival to CCU. sheaths right groin. alert and oriented but c/o some nausea, dry heaves med. with ativan 1mg with good relief.\n- sheaths d/c'd ~ 0130 (ACT 181). pressure dsg D/I. pulses + bilat.\n***first CK 219/28 #2CK 3611, MB pnd.\n- HR 70-80's SR. rare PVC. BP 100-120/60. TNG 20mcq. started lopressor 12.5mg, first dose 0300. ordered for captopril to start in AM. heparin not restarted.\n- LS clear . sats 96% on 4lnc.. denies SOB.\n- unable to void laying flat. foley placed for 300cc responce. continued to void good amts. and currently ~ even.\n- admit HCT 28. pt. with hx of anemia and takes B12 shots. ordered for one UPRBC, up at 0200. no sign of reaction. post cath IVF on hold while transfusing.\n\ndaughter visited and spoke with MD. wife coming in this morning.\npt. able to sleep very well. wakes easily.\n\nA: s/p ANT MI. s/p PTCA/stent to LAD\nP: next CK at 0900. check post transfusion HCT. continue post cath fluids for total 1l. follow VS with lopressor and captopril. monitor fluid status, LS, etc. may sit up in AM.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-19 00:00:00.000", "description": "Report", "row_id": 1535629, "text": "CCU NSG D/C SUMMARY: R/I MI\nHPA: SEE ABOVE ADMISSION NOTE\n\nCCU COURSE:\nCV: Pt r/i for MI with peak ck 3611/518 down to 2747/307 at 10am. HR has been in 90s to low 100s with rare pvcs. K+ 3.7 and he received 40 meq KCL po. He has been started on lopressor 12.5 and will receive second dose at 8pm. BP has been stable ranging 100-115/40-50s. He has received 2 doses of 6.25 captopril and tolerated it. He started rehab and was OOB to chair for one hour. He did become quite fatigued while up and has napped. His R groin is dry with no ooze or hematoma and pulses are 3+/3+ bilaterally. His feet are warm CSM nl. IV nitro was titrated off and post cath fluid d/cd.\nRESP: While lungs sound clear he is sating only 92-96%. Sat has improved with diuresis. He received lasix 20mg at 11a and lasix 40mg IV at 2pm with fair results. He has cough productive of thick bloody sputum. He has been having this for ~3-4 days. Sample was sent for\nc & S.\nGI: Pt has had no apetite today. He has been taking ginger ale and ate a little at noon, but when 2pm pills were being given he vomited a large amt of fluid. He has felt better since and has been able to take pills without vomiting. He had small G- BM.\nGI: Foley draining clear urine. He remains ~300cc + after lasix X 2.\nHEME: Crit post transfusion is 30.\nNEURO/SOCIAL: Pt has minimal L leg weakness post cerebral bleed in '. He was restarted on phenobarb for seizure profilaxis (he has never had a seizure). He is very pleasant and cooperative. His family is very supportive.\nVALUABLES: He has glasses. Family has taken valuables home.\nPLAN: Continue to maximise medications.\n Continue teaching re- rehab, and meds.\n Monitor for further crit drop\n Check results of sputum spec\n" }, { "category": "Nursing/other", "chartdate": "2176-07-20 00:00:00.000", "description": "Report", "row_id": 1535630, "text": "ccu npn 7p-7a\nS:\" Oh, I've had this cough for a couple of weeks and spitting up blood too. \"\n\nO: please see carevue for VS and objective data.\n\nCVS: Denies CP, SOB, admits to DOE. Hemodynamically stable. HR 90's-100's in the setting of temp spike as below. Given increased dose po Lopressor to 25mg at , to increase to 50mg with next dose. Tolerating po Captopril at 6.25mg TID. No vea noted, K+ 3.7 repleted with 40meq po KCL, am labs pnd. Right groin D/I without palp. hematoma. Distal pulses intact.\n\nResp; Lungs clear despite sats 92-93% on 4L n/c, sats now 94-95% on 5L n/c. Given 40mg IV Lasix at , without sign. response. Team aware. I/O at MN even, but LOS neg. 1100cc. Without further diuresis ordered at this time. U/O via foley 15-30cc/hour, neg. I/O overnoc secondary to no IV's. Pt. cont's to raise dark tan, blood tinged sputum. Repeat sample sent.\n\nID: Temp spike to 102.2 rectally. Pan cultured and given 650mg po tylenol RTC. Low grade at present. Started po Levoquin 500mg qd.\n\nGI:GU: Foley to drainage with concentrated urine at present. I/O as above. Taking po's. tolerating well. No N/V.\n\nNeuro: A/A/Ox3, pleasant and cooperative. MAE. OOB to commode with assist of one, tolerated well. DOE noted upon return to bed, resolved with rest. Slept well most of night without sleep aide required.\n\nA: Temp spike in setting of hemoptysis and MI.\n\nP: Cont to assess hemodynamics and Pt's response to increased Lopressor. increase Captopril in am. Monitor sats and pulmonary status closely. Prn diuresis. Repeat CXR in am. Follow up with cultures sent. and am labs. Comfort and emotional support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2176-07-20 00:00:00.000", "description": "Report", "row_id": 1535631, "text": "CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt alert and oriented x 3. Pt Moving all extremities spontaneously. +deconditioning. PT consult. OOB to chair x 3 hours with one assist. Ot toleratetd increased activity fairly well.\n\nCV: NSR to ST 121 no ectopy. Pt denies CP/HA/dizziness. K+ 4.1. SBP 105-138/38-64. Captopril increase to 12.5 mg po TID. Pt conts on lopressor 50mg . R groin c/d/i. Palpable pulses. CK 917. Peak 3611. 5pm CK pending. Pt to start on lipitor po tonight. Rec'd lopressor 5mg IV with results HR 108 to 90 NSR, no change in BP.\nAwaiting clarification of Echo results. ?EF 40-55%. Also awaiting clear CVA hx prior to starting coumadin per team. HCT 31.6\n\nPULM: LS with crackles bibasilary. Sats 90-94% on 5L. RR 24-30. Pt +DOE. Pt denies SOB but once he was up to a chair he stated having improvement in his breathing. Pt stated having difficulty catching his breath, team aware. Pt rec'd lasix 80mg iv x 2 with +diuresis. No peripheral edema noted. Pt with cough raising thick tan sputum this shift in small amts. Sputum with gram pos cocci in clusters and gram neg rods. Abx changed to azithromycin po and ceftriaxone iv secondary to temp spike.\n\nGI: Abd soft NT +BS. Pt with increased appetite. Denies n/v. Encouraging pt to drink. Pt having brown ob- liquid stool.\n\nGU: Foley cath patent draining cyu. u/o 25-30cc x 2 hrs this am prior to lasix doses. -1225 since mn -2335 LOS.\nGoal u/o -1l. CR 0.9 BUN 20.\n\nSKIN: intact\n\nID: Temp spike to 104.2 R. Ice packs appiled. Pt conts on tylenol po. Conts on abx. Temp currently 102 R. Pt denies any discomfort. Pan cultured within 24hrs.\n\nLINES: 2 PIV.\n\nPROPH: Hep SC.\n\nDISPO: Full Code\n\nSOCIAL: Family visiting.\n\nPt with AMI s/p PTCA/stenting. Pt febrile with productive cough and tachycardia. ? RML Pnx per report.\n\nP: Follow temp curve. Administer abx w/a.\n Follow HR/BP. Check pm CK result.\n Monitor sats. Maintain safety precautions and provide support.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-21 00:00:00.000", "description": "Report", "row_id": 1535632, "text": "ccu npn 7p-7a\nS: \"How's my temp now.\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable, HR 90-110 ST with continued temp, down to 80's NSR after 50mg po Lopressor and decreased temp. BP 90-120's/50-60. Tolerating po Captopril at 12.5mg TID. To be increased in am. CPKs trending down as per flow. K+ repletion with diuresis, am K+ pnd.\n\nResp: Sats 92-97% on 5 L n/C. Intermittenly placed on 50% cool neb secondary to dry nose. Lungs with fine bibasilar rales only to clear. Diuresised with 80mg IV Lasix with approx. 470cc response. DOE when OOB to commode.\n\nID: Continued temp to 103. rectally, received first dose of QD antibxs on previous shift. One set of BC sent with am labs as ordered. Am WBC pnd. RTC tylenol. Temp down this am.\n\nNeuro: A/A/Ox3, denies CP, SOB. OOB to commode with assist of one. MAE, transferred well though DOE noted. Slept well most of noc\n\nA: Cont'd temp to 103.\n\nP: Cont to assess temps and Pt's response to antibxs , follow up with am labs. and pnd cultures. Cont with Lopressor and increase po Captopril as ordered. Prn diuresis. Comfort and emotional support to Pt. and family\n\n" }, { "category": "Nursing/other", "chartdate": "2176-07-21 00:00:00.000", "description": "Report", "row_id": 1535633, "text": "CCU Nursing Transfer Note:\n\nMr is a 77 y/o male whom was transfered to from OSH on for cardiac cath. Pt had developed CP, diaphoresis and nausea while at work. Took SL NTG w/o effect. At OSH pt with ST elevations noted in V2-6 and 11, 111,F. Rx with heparin, NTG, morphine, lasix and lopressor. Transfered to cath lab.\n\nArrived to cath painfree. Mlad 100% stent x1 to 60% with TIMI 3 flow and RCA 60%.\n\nPMH: HTN, anemia, quit smoking 18yrs ago, CVA , minimal right residual\nAllergies: sulfa, PCN, ?ASA.\n\nSOCIAL: Married. 6 children. Retired. Pt now works at 40hrs/wk.\n\nReview of Systems:\n\nNeuro: Pt alert and oriented x 3. Pt moving all extremities. +deconditioning. Pt requires one assist with transfers. Rec. PT consult.\nOOB to chair QD.\n\nCV: NSR HR 80-90's. Pt with episode of tachycardia 8/11 HR 120's ST in presence of fever. Pt denies CP. Palpable pulses. R groin intact. Pt tolerating lopressor 50mg po BID and Captopril 25mg po. SBP 97-140.\nConts on plavix and ASA post MI. Peak CK 3611. CK's trending down. Repleting electrolytes prn.\n\nPULM: Pt with hemoptysis 3-4 days pta. Pt currently with productive cough raising thick tan/brown secretions. Pt with increased oxygen requirments . Pt currently on 5L NP with 50% cool neb intermittently. Pt with pnx and failure by CXR per report. Pt rec'd lasix IV for +diuresis. LS clear today. No peripheral edema. Currently 95% on 5L this am. +SOB with minimal activity.\n\nGI: Abd soft NT +BS. Pt tolerating cardiac diet. No n/v. OB neg stool. Pt encouraged to drink.\n\nGU: Foley cath patent draining cyu. Goal fluid status is even due to increase in Cr 1.1(0.9). Pt currently neg for LOS.\n\nID: Temp spike to 104.2 R. Pt started on azithromycin 500mg po and ceftriaxone IV. Tylenol po RTC.\n\nSKIN: intact\n\nLINES: 2 piv\n\nPROPH: hep sc and protonix po.\n\nDISPO: Full Code\n\nSOCIAL: Supportive and attentive family.\n\nA: ANT MI s/p PTCA/stenting. Conts with fever, cough, and DOE on abx.\n +deconditioning.\n\nP: Follow temp curve. Cont abx.\n Monitor response to increased captopril dose.\n Pul exam. Monitor fluid status.\n PT consult.\n Transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-21 00:00:00.000", "description": "Report", "row_id": 1535634, "text": "Addendum to Nursing Transfer Note:\n\nPt with decreased u/o 15-20cc/hr. Pt drinking well. Team attributes decreased u/o to diuresis and overnight. Pt receiving 500cc NS bolus at 2pm. Await results. NSr HR 80's. BP stable. Pt to have CXR in radiology prior to transfer to the floor.\n\nAfebrile. Pt c/o HA dull no visual changes, refused tylenol. HA resolved spontaneously within 35 min.\n\nOOB to chair x 4hr today. Pt tolerated increased activity well.\n\nTransfer to floor.\n" }, { "category": "Echo", "chartdate": "2176-07-19 00:00:00.000", "description": "Report", "row_id": 70519, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p anterior myocardial infarction.\nHeight: (in) 70\nWeight (lb): 150\nBSA (m2): 1.85 m2\nBP (mm Hg): 112/52\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 14:09\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.\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\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: anterior apex - akinetic; septal apex- akinetic;\ninferior apex - hypokinetic; lateral apex - hypokinetic; apex - akinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nborderline normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated.\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. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Resting regional wall motion\nabnormalities include distal anterior, septal, distal inferior and apical\nakinesis. Right ventricular systolic function is borderline with apical\nakinesis. The ascending aorta is mildly dilated. The aortic arch is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2176-07-22 00:00:00.000", "description": "Report", "row_id": 154408, "text": "Sinus tachycardia, rate 102\nLeft atrial enlargement\nAcute Anterior myocardial infarct\nMinor ST segment elevation inferiorly\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2176-07-23 00:00:00.000", "description": "Report", "row_id": 154409, "text": "Sinus tachycardia, rate 110\nAcute Anterior infarct\nConsider prior Inferior myocardial infarct\nSince last ECG, no significant change\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2176-07-21 00:00:00.000", "description": "Report", "row_id": 154410, "text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . Further evolution of acute anterolateral and apical myocardial\ninfarction. Followup and clinical correlation are suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2176-07-20 00:00:00.000", "description": "Report", "row_id": 154411, "text": "Sinus rhythm. ST segment elevations in leads II, III, aVF and V1-V5, increased\nas compared to the previous tracing of and, in the context of increase\nin rate, are consistent with extension and/or renewed ischemia. Rule out\ninfarction. Followup and clinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2176-07-19 00:00:00.000", "description": "Report", "row_id": 154412, "text": "Sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof , there has been loss of precordial forces with Q waves in\nleads V2-V4, with persistent ST segment elevation, consistent with evolving\nanterolateral myocardial infarction. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-07-18 00:00:00.000", "description": "Report", "row_id": 154413, "text": "Sinus rhythm. ST segment elevations in leads II, III, aVF and V1-V6 consistent\nwith acute anterolateral and apical transmural ischemia. Rule out infarction.\nFollowup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2176-07-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 740893, "text": " 3:08 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for pneumonia versus pulmonary edema (clinical pict\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with acute mi s/p cath\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia versus pulmonary edema (clinical picture of fever to\n 104, s/p actue mi and cath)\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, : Compared to .\n\n CLINICAL INDICATION: Fever.\n\n The heart is upper limits of normal in size. There is cephalization of the\n pulmonary vasculature. There is an improving central perihilar alveolar\n pattern in both lungs. There is a focal area of increased opacification\n overlying the right first anterior rib.\n\n A small amount of fluid is seen within the fissures. No definite pleural\n fluid is identified in the costophrenic sulci.\n\n IMPRESSION: 1) Slight improvement in central bilateral alveolar pattern and\n resolution of peripheral interstitial pattern, likely due to resolving\n pulmonary edema. It is difficult to exclude underlying infectious process and\n continued follow up is suggested. 2) Focal opacity overlying right first\n anterior rib. It is difficult to determine whether this represents a\n sclerotic rib lesion or a lung nodule overlying the rib. An apical lordotic\n chest radiograph may be helpful to assess this area in a different projection.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740807, "text": " 6:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with AMI, recent stent placement, and CHF - With Hemoptys\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with HTN, CVA, CAD\n REASON FOR THIS EXAMINATION:\n Pt with AMI, recent stent placement, and CHF - With Hemoptysis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AMI and CHF and hemoptysis.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n No previous chest x-rays on PACS record for comparison.\n\n There are multifocal interstitial infiltrates, predominantly perihilar but\n also seen at the right and to a lesser extent at the left bases. No upper\n zone redistribution to confirm the presence of CHF. No frank consolidation.\n No effusion. Clustered rounded densities projecting over the right apex/1st\n rib--? calcified granulomas.\n\n IMPRESSION:\n\n 1) Multifocal interstitial infiltrates. Differential diagnosis includes\n infectious and inflammatory etiologies. PDX also includes CHF, but there is\n no clear upper zone redistribution, making this less likely.\n\n 2) Probable clustered calcified granulomas. Clinical correlation requested.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740827, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 77 yo s/p anterior MI with evidence of pulmonary edema on pr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with HTN, CVA, CAD as above\n REASON FOR THIS EXAMINATION:\n 77 yo s/p anterior MI with evidence of pulmonary edema on prior CXR\n want to evaluate progression of congestion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypertension CVA CAD S/P anterior MI, with pulmonary edema, ?\n progression.\n\n CHEST, SINGLE AP VIEW\n\n There are diffuse interstitial infiltrates, with focal areas of more confluent\n alveolar opacification. The findings are most prominent in the perihilar\n region. Minimal blunting right costophrenic angle, without other evidence of\n effusion. Compared with 1 day earlier, inspiratory volumes are smaller, which\n could contribute to accentuation of these findings. However, I suspect an\n interval increase in the infiltrates.\n\n IMPRESSION: Diffuse interstitial and patchy alveolar infiltrates, most\n prominent in the perihilar regions. Most likely etiology, given the time\n course, is CHF. An infectious etiology is in the differential, but\n is considered less likely.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-21 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 740911, "text": " 11:23 PM\n CT ABDOMEN W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Pt with spiking fevers post MI, and abdominal pain on exam.\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with hx htn, intracranial bleed, recent anterior MI\n REASON FOR THIS EXAMINATION:\n Pt with spiking fevers post MI, and abdominal pain on exam. Please evaluate\n for hematoma, abscess, mesenteric ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever after MI with abdominal pain\n\n TECHNIQUE: Contiguous helical imaging is obtained from the lung bases to the\n pubic symphysis utilizing the general abdominal protocol.\n\n CONTRAST: 150cc of Optray contrast used secondary to debilitated state.\n\n CT SCAN OF THE ABDOMEN WITH CONTRAST: The lung bases demonstrate a right\n middle lobe alveolar opacity that could either represent more confluent\n atelectasis or a focus of pneumonia. Also seen is a tiny pulmonary nodule\n in the right lobe that could be inflamatory in nature. The liver demonstrates\n a tiny low attenuation focus measuring 9mm within the medial segment of the\n left lobe of the liver likely is a benign finding such as a hepatic cyst,\n bile duct hamartoma or a hemangioma. The gallbladder is not distended but does\n contain some gallstones. The kidneys, adrenals, pancreas and spleen are normal\n in appearance. Unopacified loops of bowel in the abdomen are normal. The\n abdominal aorta is of normal caliber. The SMA, celiac axis and renal arteries\n are patent. No intra-abdominal free air or free fluid.\n\n CT SCAN OF THE PELVIS WITH CONTRAST: The pelvic loops of bowel are\n unremarkable. Foley catheter is seen within the bladder. There is no\n significant pelvic lymphadenopathy or pelvic free fluid.\n\n BONE ELEMENTS: No suspicious lytic or sclerotic foci are seen. Cannulated\n screws are seen within the right femoral neck.\n\n IMPRESSION: Alveolar opacity seen in the medial segment of the right middle\n lobe that either could represent more confluent atelectasis or a focus of\n pneumonia. Also seen is a pulmonary nodule likely inflamatory in nature.\n\n No acute intra-abdominal pathology.\n\n Gallstones\n\n" } ]

[ { "category": "Physician ", "chartdate": "2125-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543686, "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 ARTERIAL LINE - STOP 04:45 PM\n > Tolerated SBT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:31 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 94 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 94 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube, diminished\n secretion\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\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 : , Diminished: bases,\n Rhonchorous but markedly improved from : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: painful stim, Movement: Non\n -purposeful, Tone: Normal\n Labs / Radiology\n 10.5 g/dL\n 573 K/uL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n All Clx data: NGTD\n Imaging: CXR : improving pattern\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ) and we are going to wean steroids further as well as abx\n regiment\n - D/c ceftriaxone today, cont levaquin (and plan stop tomorrow)\n - Cont PS ventilation: SBT today.\n - Decrease to methylprednisolone 60 mg IV q 6h \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n - Goal net negative today (500 cc) she seems to be concentrated by labs\n - Hopeful for extubation today.\n >ETOH withdrawl / altered mental: she is less responsive this morning\n then previously although there is no focality to her exam. We will hold\n all sedating medications, would check head CT to r/o any interval\n change, there is no clear metabolic precipitant and we can check a ABG\n to rule out CO2 retention. Sub-clinincal status is also on the\n differential in the setting of her EtOH withdrawl and we can also check\n B12, TSH, RPR.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n - Hopeful for improved for mental status\n Coagulopathy: elevated INR, probably related in some part to cirrhosis\n and nutritional deficiency. We will trial three days of Vitamin K.\n Other issues per ICU resident note\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots, 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 Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543116, "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 BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Crackles : , Rhonchorous: )\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 9.0 g/dL\n 379 K/uL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure with\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status at this point but\n with her elevated LDH we are suspcious for PCP. cont to cover\n broadly at this point for CAP as well as PCP (including steroids). In\n addition, we will cover with Vanco, CTX ,azithro and Bactrim pending\n the results of the BAL.\n Her plateau pressures are not consistent with ARDS, there is no\n evidence of bleeding which would go for DAH, we will await the cell\n count to eval for evidence of eosinophilic PNA. Would favor placing\n - Empiric coverage as above\n - increase PEEP and try to incrase FiO2 goal 60%\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, 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 Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544493, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:33 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds:\n Crackles : scattered )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 12.7 g/dL\n 559 K/uL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Change to Solumedrol 60 mg IV q12hr with change to PO prednisone\n tomorrow.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor ( \n Pulmonary Consult\n Fellow)\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n She has been afebrile since .\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved to the point where she is at her\n baseline\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544187, "text": "41yo F with history of asthma, EtOH abuse, and psych history (cutting),\n admitted to MICU with severe pneumonia and respiratory failure\n requiring intubation with high O2 requirements on vent. Extubated \n and found to have high O2 requirements and altered MS. Pt now satting\n >93% on 3L NC, MS improving significantly with pt A&Ox3, engaging in\n conversation, tolerating POs. Probable call out .\n Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Frequent reorientation.\n Response:\n Pt with MS greatly improving throughout day and pt A&Ox3 this pm. Pt\n able to engage in conversation, tolerating POs and able to feed self\n with little help.\n Plan:\n Cont to monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% this AM on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to 3L\n NC and no high flow O2 by mid morning and pt satting 93-98%.\n Plan:\n Aspiration precautions, T/C/DB encouragement and encouragement to clear\n secretions. Close monitoring sats, airway. Encouragement incentive\n spirometer. OOB activity with nurse assist.\n" }, { "category": "Respiratory ", "chartdate": "2125-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543635, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 4 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: White / Thin\n Sputum source/amount: Suctioned / Copious\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: No issues with vent, unless pt was beign turned, or if\n sedation was not adequte\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH; Comments: Pt performed very\n strong RSBI, showing tolerance for further weaning.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt to continue current support\n BEDSIDE RSBI- 21\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543360, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 539 mL\n PO:\n TF:\n 509 mL\n 225 mL\n IVF:\n 3,397 mL\n 264 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 436 K/uL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP ) and her WBC\n conts to rise in the setting of broad spectrum coverage. The Chest CT\n from shows a dramatic GGO and consolidation pattern in the upper\n lobes predominantly which could be consistent with AEP,PAP and possibly\n some volume overload (increased BNP on admission)\n - Empiric coverage as above\n - F/u viral studies: Ag pending\n - Cont PS ventilation\n - increase methylpred to 125 mg IV q 6h\n - Net neg fluid balance\n - Check IgE (add on to admit)\n Lactic acidosis/Increased renal failure: improvement in renal\n function and lactate. Will cont to trend.\n ETOH withdrawl: on midazolam, may need CIWA and haldol in the\n extubation setting.\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB, mouth care, daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2125-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543796, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, and levoflox,. Blood cx's sent. Leukocytosis.\n Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. But pt\ns daughter has also informed\n team that pt. drinks a pint and a half of alcohol per day and 2 packs\n cigs/day\n Significant Events: Exubated today at 1530 and put on aerosol face\n mask, given 20 mg lasix, and 0.2 mg flumenazil x2 as pt had crackles at\n the bases, Sp02 in the 80\ns with a bucket mask, and was not mentally\n alert enough to deep cough benzos on board\n Pneumonia, other\n Assessment:\n Received pt on Sp02 100%. Mod amounts of thin white secretions.\n Lungs rhonchus.\n Action:\n Exubated and put on aerosol mask with Fi02 80% with Sp02 96-98%;\n monitored resp status; 20 lasix given right after exubation and\n responded appropriately. ABG drawn an hour after exubation-\n 7.50/50/117. Reduced Fi02 to 40%\n Response:\n Pt currently on aerosol flow mask Fi02 40% with Sp02 92% RR 20\ns. Lungs\n clear; crackles at bases. Moderate amounts of thin white secretions\n suctioned when intubated (-) for secretions since exubation- shallow\n non-productive cough. Currently -2800 cc\n Plan:\n Continue to watch resp status; adjusting 02 as needed.\n Altered mental status (not Delirium)\n Assessment:\n Received pt on 2.5 mg versed drip. Not following commands. Withdrawing\n to painful stimuli. Opening eyes to painful stimuli only. No verbal\n response as was intubated. Pupils 3mm equal and sluggishly reactive.\n Moving all extremities.\n Action:\n Stopped versed drip for exubation- gave 0.2 mg x2 of flumenazil as pt\n was not awaking appropriately after exubation and though to be \n benzos on board.\n Response:\n Pt more alert; opening eyes to voice, beginning to track. Moving legs;\n lifts and drops arms. Not following commands\n Plan:\n Continue to assess mental status.\n" }, { "category": "Physician ", "chartdate": "2125-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543759, "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 ARTERIAL LINE - STOP 04:45 PM\n > Tolerated SBT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:31 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 94 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 94 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube, diminished\n secretion\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\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 : , Diminished: bases,\n Rhonchorous but markedly improved from : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: painful stim, Movement: Non\n -purposeful, Tone: Normal\n Labs / Radiology\n 10.5 g/dL\n 573 K/uL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n All Clx data: NGTD\n Imaging: CXR : improving pattern\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ) and we are going to wean steroids further as well as abx\n regiment\n - D/c ceftriaxone today, cont levaquin (and plan stop tomorrow)\n - Cont PS ventilation: SBT today.\n - Decrease to methylprednisolone 60 mg IV q 6h \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n - Goal net negative today (500 cc) she seems to be concentrated by labs\n - Hopeful for extubation today.\n >ETOH withdrawl / altered mental: she is less responsive this morning\n then previously although there is no focality to her exam. We will hold\n all sedating medications, would check head CT to r/o any interval\n change, there is no clear metabolic precipitant and we can check a ABG\n to rule out CO2 retention. Sub-clinincal status is also on the\n differential in the setting of her EtOH withdrawl and we can also check\n B12, TSH, RPR.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n - Hopeful for improved for mental status\n Coagulopathy: elevated INR, probably related in some part to cirrhosis\n and nutritional deficiency. We will trial three days of Vitamin K.\n Other issues per ICU resident note\n Patient on minimal vent requirements / good cough and minimal\n secretions. Although somnolent and not following commands we will\n proceed with extubation.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots, 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 Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2125-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542886, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. Mother is . MD will need to speak\n with mother for consent and further history if known.\n ROS:\n Neuro: Well sedated on 100mcg of fentanyl and 5mg versed. Arousable to\n voice but attempting to sit up in bed, strong cough, worrisome that she\n could dislodge ETT. Inconsistently following commands. PERL and\n sluggish. Bolus sedation needed to properly sedate patient. B/l wrist\n restraints in place.\n Cardiac: HR 80-90 sr with no ectopy. SBP 90-100 via art line. Hct 27\n down from 32 but received 5L IVF.\n Resp: On a/c 400X26 100% +8peep. RR 26-30 with sats 94-100%. Abg\n 7.36/37/142/22. Ls rhoncherous with bibasilar crackles. Sxted for scant\n sputum. Following ARDS net ventilation.\n Gi/Gu: Abd soft and distended with hypoactive bs, no stool. Uop\n 20-30cc/hr amber and clear.\n Pneumonia, other\n Assessment:\n As above.\n Action:\n Covering with levoflox and ceftriaxone for CAP coverage. Will keep on\n vanco until BAL/cx\ns return.\n Response:\n Afebrile. WBC unchanged @15.\n Plan:\n Continue abx as ordered. F/u on BAL and bronch cx\n" }, { "category": "Nursing", "chartdate": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543438, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine. Known h/o\n asthma and depression.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543439, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine. Known h/o\n asthma and depression.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep 10, PS 8, Sats 93-96%. Ls\n rhoncherous throughout. Strong cough with small to moderate amount\n white thick sputum. CXR showed diffuse b/l opacities but improved\n over previous day .CT scan performed showed diffuse opacities\n throughout the lungs with chronic pancreatitis . No back flow from\n A-line, ABG pending.\n Action:\n sedation weaned off to 50mcgs of fent and 5 mg of versed. PT remains\n on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n .Pt seems comfortable with the PS. Of note pt is a long time smoker of\n 1 ppd and is a heavy drinker 91.5 pints /day) with a history of\n withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation if tolerated.. F/u on am\n CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous, improved after lasix 20 mg IV. Tmax 99 , moderate\n amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc remain elevated.. Lactate : 0.6.,\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Hyperglycemia\n Assessment:\n FSBS >200 mg/dl.\n Action:\n Insulin gtt started @ 3 unit/hr & titrated as per blood sugar.\n Response:\n Last FSBS 120\n Plan:\n Will cont hourly FSBS\n" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543944, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n CT head (-) for bleed or focal pathology -\"no change since \"\n TSH/B12/RPR added-on for mental status changes\n Steroids tapered to 60mg q6\n Stopped ceftriaxone, continued levofloxacin\n Extubation - 4pm - received 0.2mg x2 flumazenil for somnolence post\n extubation\n Lasix 20mg iv x1\n NGT placed, lactulose started\n Showed progressive neurological improvement through evening, but\n continued difficulty following commands\n ~1215 am - ~50cc coffee ground emeis post dry heaving. NG lavage\n performed with ~250cc water, ~150 returned with no e/o of blood. Stat\n hct stable at 32 and 31. Stopped famotidine, started iv protonix,\n cross matched 2uPRBCs.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 AM\n Other medications:\n Changes to medical and family history:\n Talked with daughter this AM. Social history: drinking pints vodka\n daily (depending on financial situation at the time). Smokes 1 to 1.5\n PPD. No known history of IVDU. No known history of liver disease.\n Has had long history of EtOH abuse with withdrawals in the past. Also\n has history of\nbrain damage\n reports that patient went into coma\n about 10-12 years ago, unclear reason ?drug use. Reports told that she\n had anoxic injury. Lives at home and takes care of self on own, able\n to ambulate safely without assistance, speech/language reportedly\n normal at baseline, though overall not quite as\nwith it\n as before her\n coma. Daughter also reports history of\nnerve damage\n to hands/feet\n thought due to alcohol. Complains of being unable to feel hands and\n write well due to numbness at baseline.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 88 mL\n PO:\n TF:\n IVF:\n 445 mL\n 88 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (507 - 624) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 36%\n PIP: 10 cmH2O\n SpO2: 95%\n ABG: 7.50/50/117/38/13\n Ve: 8.2 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese. In chair. Lethargic but arousable. States name with some\n slurring.\n Eyes / Conjunctiva: PERRL, resists eye opening. Anicteric sclerae.\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal) no murmurs\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 but significantly improved, much more clear.\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Trace edema\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands (hands and feet), Can\n state name, not oriented to place or date. Moves all extremities\n spontaneously, but no/little response to painful stimuli of\n fingers/hands. Does respond to pain in move proximal upper and lower\n extremities.\n No neck or back TTP.\n Labs / Radiology\n 574 K/uL\n 10.6 g/dL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n # Acute pneumonia and respiratory failure.\n clinically improving, now\n extubated successfully. Picture C/w noninfectious cause, +eos in BAL\n and elevated serum IgE, ?AEP. ANCA and infection workup negative.\n - continue solumedrol 60 Q6hrs for one more day (changed )\n tomorrow can decrease to 60 Q8 or 12.\n - start bactrim given anticipated prolonged steroid course.\n - cont levoflox to complete tentative 10d course .\n - goal even today (has been significantly negative with metabolic\n alkalosis; will let be even or autodiurese some on own today).\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy duie to alcohol, though not yet\n at baseline (lives/functions at home alone). Given this history,\n picture consistent with global deleriumt (med effect, infections,\n steroids etc). CT without contrast negative for bleed. B12, folate,\n TSH negative. More concerning was lack of withdrawal to pain on exam\n yesterday/today, though this likely due to baseline peripheral\n neuropathy per daughter.\n - f/u RPR\n - check ammonia\n - continue to monitor exam\n - hold benzos, though monitor for withdrawal.\n - consider further imaging or neuro consult if not improving.\n # Coffee ground emesis. One episode overnight after dry heaving;\n likely vs. past OGT trauma vs. more worrisome causes\n (gastritis, esophagitis, PUD). Seems to be self limited with\n subsequent stable Hct.\n - recheck hct this afternoon.\n - ppi\n - Recheck coags; getting vitamin K for mildly increased INR\n - If no further episodes and hct stable, would hold off on GI\n consult/scope\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\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" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543949, "text": "Chief Complaint: Hypoxic resp failure AEP and asthma\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 HPI: 41 F with history of asthma, recently initiated treatment for\n atypical pneumonia, now represents to ED for severe pneumonia and\n respiratory failure requiring intubation. Patient seen on for R\n sided chest pain, shortness of breath and cough. Discharged from ED on\n azithromycin after CXR showing atypical pneumonia. Normal O2 per ED\n notes from that visit. Did not improve at home and represented to ED\n yesterday evening. Per EMS report, O2 sat 65% upon their arrival.\n In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of\n hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L NS\n given, also vanc, levoflox, cefepime, bactrim. Tachypneic to 40-50s;\n intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8 70% FiO2 prior\n to arrival to floor.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n poor mental status\n now improving\n Brain CT\n no acute changes\n Coffe-ground vomit, but gastric lavage negative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 AM\n Other medications:\n Changes to medical and family history:\n PMH:\n asthma\n ?cutting behavior/depreesion (seen on exam).\n EtOH-ism\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 93% on3L NC\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 86 mL\n PO:\n TF:\n IVF:\n 445 mL\n 86 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -404 mL\n Respiratory support\n 3L NC\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: CTA ant\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Oriented only to self\n Labs / Radiology\n 10.6 g/dL\n 574 K/uL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ) and we are going to wean steroids further as well as abx\n regiment. Extubated and doing well on 3L NC.\n -Continue steroid taper: goal to get down to 60 of prednisone (or\n equivalent) w/n one week\n -Bactrim for PCP \n x 10 days for atypical PNA (?)\n -Supplemental O2\n -OOB/chair\n >ETOH withdrawl / altered mental: CT head negative. Neuro exam is\n improving.\n -Will continue to monitor\n -No evidence of EtOH w/d at this time. Will monitor\n -Continue lactulse for ? hepatic encephalopathy\n > Coffee-ground emesis: resolved\n -Cotninue PPI\n Coagulopathy: elevated INR, probably related in some part to cirrhosis\n and nutritional deficiency. Three days of Vitamin K.\n Other issues per ICU resident note\n ICU Care\n Nutrition: Start TF\n Glycemic Control:\n Lines: Will place PIV and d/c central line\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30min\n" }, { "category": "Nursing", "chartdate": "2125-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543861, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt very lethargic, sleeping most of shift, arouses to voice, nonverbal,\n making incomprehensible sounds. Pt does not follow commands. Pt will\n withdraw to pain but with about 30sec delay in reaction.\n Action:\n Frequent neuro checks. Started on lactulose and holding all sedatives.\n Response:\n Ongoing assessment, pt has become more alert over course of the night.\n Plan:\n Cont neuro checks, hold all sedatives.\n Pneumonia, other\n Assessment:\n Pt s/p extubation yesterday. LS clear in bilateral upper lobes,\n crackles over left base.\n Action:\n Pt weaned to 40% Hi-flow with 2.0L NC. Chest PT given.\n Response:\n Sats mid 90s, pt will occas wiggle O2 mask off. Pt with good cough,\n expectorating large amounts of frothy white secretions.\n Plan:\n Cont to wean O2 as tolerated. Chest PT, encourage to cough and deep\n breathe.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt acutely developed frothy coffee ground emesis, dry heaving after\n turning.\n Action:\n NGT placed to LWS with small amount of BRB return. Hct sent. Dr.\n paged to bedside, and performed NG lavage with minimal pink\n tinge to water.\n Response:\n Hct stable, no further signs of bleeding.\n Plan:\n Cont monitor.\n Of note, pt is having menstrual period, pads in place.\n" }, { "category": "Physician ", "chartdate": "2125-10-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 542971, "text": "Chief Complaint: Shortness of breath\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 41 yo with hx of ?asthma, recently seen in the ED and prescribed a\n Z-pak which she took. She became progressively dyspneic, with cough and\n malaise. Progressively worse at home, O2 sat of 65% at home with EMT.\n She received 5L of NS for transient hypotensive and received\n Vancomycin, levocfloxacin, Cefepime and Bactrim (PCP tx dose). She was\n intubated for hypox resp failure. Dr. reports on bronch it was a\n clear bronch with clear fluid returned and no purulence in the airways.\n She\n Patient admitted from: ER\n History obtained from Medical records, house officer\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 03:47 AM\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Anxiety/Depression\n Self mutilatory behavior\n non contrib\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: unknown social histry\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 10:20 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: 36.2\nC (97.2\n HR: 92 (84 - 93) bpm\n BP: 104/64(78) {94/60(72) - 106/68(81)} mmHg\n RR: 27 (27 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,215 mL\n PO:\n TF:\n IVF:\n 865 mL\n Blood products:\n Total out:\n 0 mL\n 311 mL\n Urine:\n 311 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,904 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 947 (300 - 947) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 80%\n RSBI: 67\n PIP: 26 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 99%\n ABG: 7.36/37/142/21/-3\n Ve: 11.8 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: OG tube\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: (Breath Sounds: Crackles : diffusely, Diminished:\n bases, Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n 348 K/uL\n 27.1 %\n 8.9 g/dL\n 203 mg/dL\n 0.5 mg/dL\n 12 mg/dL\n 21 mEq/L\n 108 mEq/L\n 3.9 mEq/L\n 136 mEq/L\n 15.7 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n WBC\n 15.7\n Hct\n 27.1\n Plt\n 348\n Cr\n 0.5\n TropT\n 0.04\n TC02\n 22\n Glucose\n 203\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:13/24, Alk Phos\n / T Bili:95/0.2, LDH:576 IU/L, Ca++:6.7 mg/dL, Mg++:1.8 mg/dL, PO4:2.5\n mg/dL\n Fluid analysis / Other labs: BAL fluid count.\n Microbiology: BAL pending .\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure with\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status at this point but\n with her elevated LDH we are suspcious for PCP. cont to cover\n broadly at this point for CAP as well as PCP (including steroids). In\n addition, we will cover with Vanco, CTX ,azithro and Bactrim pending\n the results of the BAL.\n Her plateau pressures are not consistent with ARDS, there is no\n evidence of bleeding which would go for DAH, we will await the cell\n count to eval for evidence of eosinophilic PNA. Would favor placing\n - Empiric coverage as above\n - increase PEEP and try to incrase FiO2 goal 60%\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 04:03 AM\n Arterial Line - 04:53 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: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2125-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543706, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:45 PM\n - lost A. line, not replaced\n - started on TID prn haldol with good effect, fentanyl stopped, remains\n on versed\n - tolerated SBT well, but had ongoing signicant secretions requiring\n frequent suctioning, so was not extubated. Also, not following\n commands.\n - received one dose of lasix IV 20 with good effect\n - RSBI of 21 this morning, but still not following commands, although\n secretions are improving (q1 hour)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:51 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 98 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 98 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -962 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 L/min\n Physical Examination\n Nad, cannot assess neurological status, downgoing toes, c5 and l4 and\n s1 wit nl reflexes, abd soft, crackles at bases, no murmurs, no scleral\n icterus.\n Labs / Radiology\n 573 K/uL\n 10.5 g/dL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia\n clinically improving, lung mechanics/rsbi robust.\n C/w noninfectious cause, +eosinophilia, ?AEP.\n - decrease solumedrol 60 Q6hrs ()\n - IgE pending (can be suggestive of AEP), ANCA (? vasculitis)\n - f/u cxs\n - cont levoflox to complete tentative 10d course , DC ceftriaxone\n # Respiratory failure\n required intubation for pna/pneumonitis. Lung\n mechanics passing sbt with adequate cough and gag. Weaning and\n extubation limited by secretions and mental status.\n - hold versed\n - (-)500cc to 1L today\n - post CT head today, plan for extubation\n # mental status changes\n med effect, epilecticus (although no PE\n findings or hemodynamic changes).\n - ct head r/o bleed (no focality to exam)\n - b12, folate, tsh, rpr\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal once extubated and off versed. Benzos prn.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition: holding feeds until extubation\n Glycemic Control: iss\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: hep sq\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu until stable\n" }, { "category": "Nursing", "chartdate": "2125-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543851, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543983, "text": "Chief Complaint: Hypoxic resp failure AEP and asthma\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 HPI: 41 F with history of asthma, recently initiated treatment for\n atypical pneumonia, which turned out to be likely eosinophilic PNA.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n poor mental status\n Brain CT\n no acute changes\n Coffe-ground vomit, but gastric lavage negative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 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 07:39 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 93% on3L NC\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 86 mL\n PO:\n TF:\n IVF:\n 445 mL\n 86 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -404 mL\n Respiratory support\n 3L NC\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: CTA ant\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Skin: warm\n Neurologic: Oriented only to self\n Labs / Radiology\n 10.6 g/dL\n 574 K/uL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: s/p extubation, tolerated well. Her\n presentation is concerning for acute eosinophilic PNA, +/- infectious\n source . BAL has been neg on gram stain and clx as have been blood clx,\n a viral process is possible (the Ag was cancelled) and urine legionella\n was neg..\n -Continue steroid taper: goal to get down to 60 of prednisone (or\n equivalent) w/n one week\n -Bactrim for PCP \n x 10 days for atypical PNA (?)\n -Supplemental O2\n -OOB/chair\n >ETOH withdrawl / altered mental: CT head negative. Neuro exam is\n improving slowly. -Will continue to monitor\n -No evidence of EtOH w/d at this time. Will monitor -Continue lactulse\n for ? hepatic encephalopathy\n > Coffee-ground emesis: resolved-Continue PPI\n Other issues per ICU resident note.\n ICU Care\n Nutrition: hold TF tonight for mental status\n Glycemic Control:\n Lines: Will place PIV and d/c central line\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 min\n" }, { "category": "Respiratory ", "chartdate": "2125-10-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543782, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n PT extubated this shift initially to 70& cool aerosol face tent however\n spo2 mid 80s and pt is now transitioned over to a hi flow setup\n currently at 80% with spo2 mid to upper 90s. Will cont to monitor for\n s/s fatigue and wean fio2 accordingly.\n" }, { "category": "Nursing", "chartdate": "2125-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543783, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, and levoflox,. Blood cx's sent. Leukocytosis.\n Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. But pt\ns daughter has also informed\n team that pt. drinks a pint and a half of alcohol per day.\n Significant Events: Exubated today at 1530 and put on aerosol face\n mask, given 20 mg lasix, and 0.2 mg flumenazil x2 as pt had crackles at\n the bases, Sp02 in the 80\ns with a bucket mask, and was not mentally\n alert enough to deep cough benzos on board.\n" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543938, "text": "Chief Complaint: Hypoxic resp failure AEP and asthma\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 HPI: 41 F with history of asthma, recently initiated treatment for\n atypical pneumonia, now represents to ED for severe pneumonia and\n respiratory failure requiring intubation. Patient seen on for R\n sided chest pain, shortness of breath and cough. Discharged from ED on\n azithromycin after CXR showing atypical pneumonia. Normal O2 per ED\n notes from that visit. Did not improve at home and represented to ED\n yesterday evening. Per EMS report, O2 sat 65% upon their arrival.\n In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of\n hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L NS\n given, also vanc, levoflox, cefepime, bactrim. Tachypneic to 40-50s;\n intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8 70% FiO2 prior\n to arrival to floor.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n poor mental status\n now improving\n Brain CT\n no acute changes\n Coffe-ground vomit, but gastric lavage negative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 AM\n Other medications:\n Changes to medical and family history:\n PMH:\n asthma\n ?cutting behavior/depreesion (seen on exam).\n EtOH-ism\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 93% on3L NC\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 86 mL\n PO:\n TF:\n IVF:\n 445 mL\n 86 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -404 mL\n Respiratory support\n 3L NC\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: CTA ant\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Oriented only to self\n Labs / Radiology\n 10.6 g/dL\n 574 K/uL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ) and we are going to wean steroids further as well as abx\n regiment. Extubated and doing well on 3L NC.\n -Continue steroid taper: goal to get down to 60 of prednisone (or\n equivalent) w/n one week\n -Bactrim for PCP \n x 10 days for atypical PNA (?)\n -Supplemental O2\n -OOB/chair\n >ETOH withdrawl / altered mental: CT head negative. Neuro exam is\n improving.\n -Will continue to monitor\n -No evidence of EtOH w/d at this time. Will monitor\n -Continue lactulse for ? hepatic encephalopathy\n > Coffee-ground emesis: resolved\n -Cotninue PPI\n Coagulopathy: elevated INR, probably related in some part to cirrhosis\n and nutritional deficiency. Three days of Vitamin K.\n Other issues per ICU resident note\n ICU Care\n Nutrition: Start TF\n Glycemic Control:\n Lines: Will place PIV and d/c central line\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30min\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543070, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PCV with RR set @30, fio2 @80%, Peep +12. Overbreathing\n 34-40. Tv\ns 200-600cc\ns. Sats 95-99%. Abg 7.38/33/190. Ls rhoncherous\n with diminished bases. Strong cough with small amount white thick\n sputum. CXR from the afternoon of showed diffuse b/l opacities\n but improved over previous day.\n Action:\n Decreased fio2 to 60%, then to 40% while monitoring o2 saturation.\n Response:\n Morning abg 7.37/32/87.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 99.4. Small amount of white thick sputum. NGTD on\n blood cx\ns, Bal washings and cx\ns, PCP or urine legionella.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back and Bactrim and steroids for\n prophylaxis PCP .\n Response:\n Remains with low grade temps. Wbc up slightly to 16.6. Lactate 3.7 this\n morning.\n Plan:\n Abx as ordered, f/u on cultures.\n" }, { "category": "Physician ", "chartdate": "2125-10-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543675, "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 ARTERIAL LINE - STOP 04:45 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:31 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 94 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 94 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\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 : , Diminished: bases,\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Non\n -purposeful, Tone: Normal\n Labs / Radiology\n 10.5 g/dL\n 573 K/uL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR :\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ). Hopefuil\n - Will stop Vancomycin today, cont ceftriax/levaquin.\n - Cont PS ventilation: SBT today.\n - increase methylpred to 125 mg IV q 6h and will decrease on\n \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n >ETOH withdrawl / altered: on midazolam, may need CIWA and haldol in\n the extubation setting as her mental status is likely to be worsened in\n the setting of high dose steroids.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n Other issues per ICU resident note\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots, 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 Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543678, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:45 PM\n - lost A. line, not replaced\n - started on TID prn haldol with good effect, fentanyl stopped, remains\n on versed\n - tolerated SBT well, but had ongoing signicant secretions requiring\n frequent suctioning, so was not extubated. Also, not following\n commands.\n - received one dose of lasix IV 20 with good effect\n - RSBI of 21 this morning, but still not following commands, although\n secretions are improving (q1 hour)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:51 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 98 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 98 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -962 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 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 573 K/uL\n 10.5 g/dL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:00 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": "2125-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543679, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:45 PM\n - lost A. line, not replaced\n - started on TID prn haldol with good effect, fentanyl stopped, remains\n on versed\n - tolerated SBT well, but had ongoing signicant secretions requiring\n frequent suctioning, so was not extubated. Also, not following\n commands.\n - received one dose of lasix IV 20 with good effect\n - RSBI of 21 this morning, but still not following commands, although\n secretions are improving (q1 hour)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:00 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Haloperidol (Haldol) - 11:21 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Famotidine (Pepcid) - 08:43 PM\n Furosemide (Lasix) - 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 07:51 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: 71 (70 - 105) bpm\n BP: 127/61(77) {123/42(63) - 153/98(105)} mmHg\n RR: 9 (8 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (10 - 19)mmHg\n Total In:\n 905 mL\n 98 mL\n PO:\n TF:\n 4 mL\n IVF:\n 761 mL\n 98 mL\n Blood products:\n Total out:\n 3,310 mL\n 1,060 mL\n Urine:\n 3,310 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,405 mL\n -962 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 720 (534 - 802) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 21\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 12 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 573 K/uL\n 10.5 g/dL\n 183 mg/dL\n 0.6 mg/dL\n 34 mEq/L\n 4.6 mEq/L\n 33 mg/dL\n 105 mEq/L\n 144 mEq/L\n 31.3 %\n 15.7 K/uL\n [image002.jpg]\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n WBC\n 25.3\n 17.4\n 15.7\n Hct\n 26.7\n 28.6\n 31.3\n Plt\n 436\n 484\n 573\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.6\n TCO2\n 24\n 26\n 28\n 34\n Glucose\n 194\n 136\n 111\n 172\n 187\n 183\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumoniaNow clinically improving with requirement for less\n vent and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest ?AEP. No peripheral eosinophilia. Does have upper\n lobe predominance on CT.\n - Continue solumedrol 125 Q6 hours today.\n - checking IgE (can be suggestive of AEP), ANCA (? vasculitis)\n - follow final BAL cultures.\n - continue coverage with levoflox + cephalosporin; d/c vancomycin.\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2. Diuresed\n overnight. Weaning sedation to hopefully allow extubation today.\n - Extubate today if can wean off sedation and secretions manageable.\n SBT. Give haldol 5 mg x 1 to decrease agitation, may need some\n continued benzos given high EtOH use.\n - Negative 1.8 liters overnight\n should not need further diuresis.\n .\n # Depression. continue home prozac dose\n # Concern for EtOH abuse. Per family. Chronic pancreatitis per\n imaging. Last drink thought to be or .\n - Monitor for withdrawal once extubated and off versed. Benzos prn.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543073, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PCV with RR set @30, fio2 @80%, Peep +12. Overbreathing\n 34-40. Tv\ns 200-600cc\ns. Sats 95-99%. Abg 7.38/33/190. Ls rhoncherous\n with diminished bases. Strong cough with small amount white thick\n sputum. CXR from the afternoon of showed diffuse b/l opacities\n but improved over previous day.\n Action:\n Decreased fio2 to 60%, then to 40% while monitoring o2 saturation.\n Response:\n Morning abg 7.37/32/87. On Triadyne bed, tolerating turning side to\n side without any desaturation.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 99.4. Small amount of white thick sputum. NGTD on\n blood cx\ns, Bal washings and cx\ns, PCP or urine legionella.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back and Bactrim and steroids for\n prophylaxis PCP .\n Response:\n Remains with low grade temps. Wbc up slightly to 16.6. Lactate 3.7 this\n morning.\n Plan:\n Abx as ordered, f/u on cultures.\n" }, { "category": "Nursing", "chartdate": "2125-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543661, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, and levoflox,. Blood cx's sent. Leukocytosis.\n Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. But pt\ns daughter has also informed\n team that pt. drinks a pint and a half of alcohol per day.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep5, PS 5, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with moderate amounts of white thick sputum.\n CT scan performed showed diffuse opacities throughout the lungs\n with chronic pancreatitis .\n Action:\n Fent weaned off completely yesterday and midaz @ 2.5 mg/hr . Vent\n settings remain: PS OF 5 AND PEEP OF 5.\n Response:\n Pt seems comfortable with the PS & satting at high 90\ns. Of note pt is\n a long time smoker of 1 ppd and is a heavy drinker 1.5 pints /day) with\n a history of withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation today once patient is\n able to follow the commands & improved secretions. Am RSBI is 21.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Afebrile, moderate amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n until BAL results come back, and steroids.\n Response:\n T max 97.8 WBC continues to trend down.\n Plan:\n Abx as ordered, f/u on cultures.\n Altered mental status.\n Assessment:\n Patient opens her eyes to painful stimuli / spontaneously at times but\n does not track to follow any commands. Restless & agitated mostly ,\n trying to climb up the side rails at times.\n Action:\n Fentanyl off , midaz at 2.5 mg/hr. Halodol on PRN basis . Halodol 5\n mg IV X1 at 0530 this am.\n Response:\n Halodol IV with good effects.\n Plan:\n Will cont monitoring her mental status closely. Halodol for\n agitation.\n" }, { "category": "Nursing", "chartdate": "2125-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542862, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. Mother is . MD will need to speak\n with mother for consent and further history if known.\n" }, { "category": "Physician ", "chartdate": "2125-10-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 542863, "text": "Chief Complaint: hypoxic respiratory failure\n HPI:\n 41 F with history of asthma, recently initiated treatment for atypical\n pneumonia, now represents to ED for severe pneumonia and respiratory\n failure requiring intubation. Patient seen on for R sided chest\n pain, shortness of breath and cough. Discharged from ED on\n azithromycin after CXR showing atypical pneumonia. Normal O2 per ED\n notes from that visit. Did not improve at home and represented to ED\n yesterday evening. Per EMS report, O2 sat 65% upon their arrival.\n Further history unknown at this time.\n In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of\n hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L NS\n given, also vanc, levoflox, cefepime, bactrim. Tachypneic to 40-50s;\n intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8 70% FiO2 prior\n to arrival to floor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 03:47 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Other medications:\n MVI daily\n Prozac 60 mg daily\n Zithromax Zpack\n Percocet 1-2 tabs TID prn\n Past medical history:\n Family history:\n Social History:\n asthma\n ?cutting behavior/depreesion (seen on exam).\n unknown\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: unknown\n Review of systems:\n Cardiovascular: Chest pain\n Respiratory: Cough, Dyspnea, Wheeze\n Flowsheet Data as of 05:29 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: 84 (84 - 92) bpm\n BP: 102/68(81) {102/68(81) - 102/68(81)} mmHg\n RR: 25 (25 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 5,872 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 220 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,652 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 300 (300 - 300) mL\n RR (Set): 26\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n Compliance: 80 cmH2O/mL\n SpO2: 98%\n Ve: 11.7 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, on vent\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), distant\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: Bronchial:\n , No(t) Wheezes : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed, follows commands\n when not sedated\n Labs / Radiology\n 442\n 11.3\n 99\n 0.6\n 11\n 24\n 103\n 3.6\n 138\n 32.7\n 15.1\n [image002.jpg]\n Other labs: PT / PTT / INR://1.1, CK / CKMB / Troponin-T://<0.01,\n Differential-Neuts:85, Lymph:11, Eos:0.4, LDH:740\n Imaging: CXR: widespread diffuse airspace opacities, most prominent\n bilateral hila, L>R. No effusion. ETT in satisfactory position.\n .\n Bronch (urgent in ED): normal limited airway exam. RML BAL done.\n Microbiology: blood cultures pending\n ECG: ECG: NSR at 94. NANI. No ST segment changes. No significant\n interval change.\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent.\n # Acute pneumonia. Initiated treatment for pneumonia 2 days PTA with\n azithromycin but did not improve. Patient with widespread pulmonary\n infiltrates, leukocytosis, mildly elevated temps. Significant O2\n requirement as below. Patient with history of asthma, no on steroids\n or other known immunosuppressants; no known risk factors for unusual\n organisms (fungals: histo/blasto, coccidio; PCP have elevated\n LDH) though little is known about her history and risk factors for\n these diseases. Also consider usual CAP organisms, staph, legionella.\n Noninfectious pneumonia also a possibility (AEP, AIP), alveolar\n hemorrhage less likely given appearance of BAL fluid.\n - BAL for cell count pending.\n - Also checking PCP stain, fungal cultures, AFB, rapid respiratory\n viral, legionella, cytology of BAL.\n - urine legionella Ag.\n - Cover for severe CAP coverage (levoflox + cephalosporin). Will\n continue vanc in addition empirically until data from BAL returns.\n ?Bactrim for PCP , ?steroids in addition.\n - Monitor hemodynamics, no evidence of hypotension/shock thus far. If\n so, needs CVL.\n - Collateral info from family.\n .\n # Respiratory failure. Requiring intubation. Now on ARDSnet volumes,\n currently at FiO2 0.7 and PEEP 8.\n - ARDSnet ventilation.\n - versed/fent\n - CXR daily\n - VAP precautions.\n - Daily wake up.\n .\n # Depression. continue home prozac dose.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:03 AM\n Arterial Line - 04:53 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543340, "text": "Chief Complaint:\n 24 Hour Events:\n Vanco, levo, ctx continued, bactrim discontinued\n CT chest: Diffuse ground glass opacities, worst in the upper lobes with\n possible crazy paving appearance. Dependent nodular opacities at the\n bases. Differential is broad and includes infectious and inflammatory\n etiologies such as pneumocystis pneumonia, pulmonary alveolar\n proteinosis, and noncardiac edema. Other less likely etiologies\n include bacterial pneumonia, chronic eosinophilic pneumonia,\n hypersensitivity pneumonitis and pulmonary hemorrhage. Extensive\n pancreatic calcifications.\n Family reported concern for ethanol withdrawal - ct showing chronic\n pancreatitis.\n NGT placement.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n FINGERSTICK GLUCOSE: 194-280 (since start of RISS)\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 562 mL\n PO:\n TF:\n 509 mL\n 236 mL\n IVF:\n 3,397 mL\n 276 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General: Intubated/sedated. Somewhat responsive to voice and commands.\n HEENT: ETT in place.\n Chest: Continues to be very coarse and rhonchorous, though good\n volumes. No wheeze.\n Heart: RRR, distant behind breath sounds\n Abdomen: soft, NT/ND, no mass.\n Extrem: warm, no sacral or extremity edema.\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 436 K/uL\n 8.9 g/dL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n MICRO: viral culture : pending; rapid pending.\n PCP negative 2\n Sputum culture prelim neg\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia. Initiated treatment for pneumonia 2 days PTA with\n azithromycin but did not improve. widespread pulmonary infiltrates,\n leukocytosis, mildly elevated temps, significant O2 requirement and\n vent support. Now clinically improving with requirement for less vent\n and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest ?AEP. No peripheral eosinophilia. Does have upper\n lobe predominance on CT. PAP also in differential prelim\n radiographically (also see high LD with this, though nonspecific), but\n not consistent with course or ongoing secretions.\n - Continue steroids (initially on for PCP treatment with bactrim, will\n continue for presumptive diagnosis of AEP). Increase today to\n solumedrol 125 Q6 hours.\n - check IgE (can be suggestive of AEP), ANCA (? vasculitis)\n - follow final BAL cultures and rapid viral studies.\n - For now will continue coverage for severe CAP coverage (levoflox +\n cephalosporin and vancomycin).\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2.\n - Try decrease PEEP to 5 this AM, hope for extubation likely tomorrow\n AM.\n - versed/fent with daily wake up\n - CXR daily\n - VAP precautions.\n - Diurese today to optimize pulmonary function\n 20 IV lasix now and\n goal negative 1+ liter.\n # Renal function. Creatinine within normal limits but significant bump\n yesterday, now improved. Stopped bactrim.\n .\n # Depression. continue home prozac dose\n # Concern for EtOH abuse. Per family. Chronic pancreatitis per\n imaging. Last drink thought to be or .\n - Monitor for withdrawal once extubated and off versed.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU care\n NUtren pulmonary\n Insulin sliding scale\n H2 blocker\n HSQ\n CVL and Aline\n Full code\n Dispo: ICU\n" }, { "category": "Nursing", "chartdate": "2125-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543344, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past\n has been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****Started on Solumedrol 125 mg IV Q6\n hrly..\n ***** Lasix 20 mg IV given X1, good response.\n **** Goal is neg 500 cc out.\n ***** Weaning off fentanyl first as tolerated .\n ***** Insulin drip started , goal FSBS 150 mg/dl.\n ***** Vent parameter changed , Repeat ABG X1.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on Vent CPAP, 40%, 10 PEEP, PS : 5.. On fent @ 150 mcg/hr,\n Midaz 10 mg/hr.\n Action:\n . Fentanyl increased to 175 mcg/hr & Midaz to 8 mg/hr for comfort .\n Weaned off sedation to 100 mcg/hr fentanyl & midaz 6 mg/hr. Vent\n parameter changed to PCV/ 80% /rate :30, PEEp : 12. . ABG sent X2.\n Last ABG 7.34/39/80 . Suctioned frequently for moderate white thin\n secretions. Bronchoscopy done at bedside, bronchial wash sent for\n analysis. ET tube rotated & retaped.\n Response:\n Satting at high 90\ns on PCV, desatted at high 80\ns & tachypnic when\n increased PEEP & other vent changes. Refer flowsheet for details.\n Overbreathing on vent at times @ 32-36 bpm.\n Plan:\n Wean FiO2 & vent parameters as tolerated. Repeat ABG as needed. Plan\n to place new A line ( as there is no back flow from the old one)\n Pneumonia, other\n Assessment:\n Lungs auscultation reveals : Bilat upper lobes rhonchi, bilat lower\n lobes : crackles. CXR done . WBC : 15.7\n Action:\n CXR shpws diffuse opacities, L>R , No effusion. On Levoflox &\n cephalosporin ( for CAP coverage). & Vanc IV empirically.\n Response:\n .SBP between 90-110 mm of hg.\n Plan:\n F/U Blood culture & BAL . Will cont on Bactrim ( for PCP),\n Cephalosporin & Levoflox ( For CAP coverage ) & VANCO empirically\n until data from BAL returns.\n Fever ( unknown origin)\n Assessment:\n T max : 102.9. WBC : 15.7\n Action:\n Tylenol 650 mg + 325 mg per OG tube given. Sponge bath given.\n Panculture sent.\n Response:\n Patient diaphoretic. Temp at 99.2.\n Plan:\n F/U culture & will cont Abx..\n Low urine output\n Assessment:\n Urine output ml/hr.\n Action:\n Urine sent for culture & legionella.m No fluid bolus given during\n this shift.\n Response:\n MD notified. No improvement noted.\n Plan:\n F/U with lab result. Cont monitoring Urine output.\n" }, { "category": "Respiratory ", "chartdate": "2125-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543541, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\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: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n MDIs given as documented\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt continues on +5PSV/+5PEEP, passed SBT today - possible\n extubation in AM. Pt still has moderate amounts of thick white\n secretions, has strong cough. doesn't consistently follow commands,\n does get agitated.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n extubation in AM\n" }, { "category": "Respiratory ", "chartdate": "2125-10-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 542962, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Elective\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: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n :\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min), Active exhalations, High flow demand;\n Comments: pt remains orally intubated on full mechanical support.\n multiple vent changes made to attempt to optimize pulmonary status. pt\n now on PCV, seems the most comfortable that she has been all shift.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Dysynchrony assessment: Vigorous inspiratory efforts, Erratic exhaled\n Tidal Volumes\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1400)\n Comments: BAL sent for culture, PCP.\n" }, { "category": "Nursing", "chartdate": "2125-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543346, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past\n has been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****Started on Solumedrol 125 mg IV Q6\n hrly..\n ***** Lasix 20 mg IV given X1, good response.\n **** Goal is neg 500 cc out.\n ***** Weaning off fentanyl first as tolerated .\n ***** Insulin drip started , goal FSBS 150 mg/dl.\n ***** Vent parameter changed , Repeat ABG X1.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep 10, PS 8, Sats 93-96%. Ls\n rhoncherous throughout. Strong cough with small amount white thick\n sputum. CXR showed diffuse b/l opacities but improved over\n previous day .CT scan performed .\n Action:\n Vent sedation remains at 150mcgs of fent and 10 mg of versed. PT\n remains on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n Please see Metavision for ABG\nS. Pt seems comfortable with the PS. Of\n note pt is a long time smoker of 1 ppd and is a heavy drinker with a\n history of withdraws per the daughter. Pt also had a CT of the chest\n to further investigate the lungs and results are pending.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 97.8 moderate amounts of white thick sputum. NGTD\n on blood cx\ns, Bal washings and cx\ns. PCP and urine legionella have\n been R/O.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids.\n Response:\n Remains afebrile throughout this shift. Wbc remain elevated am labs\n are pending. last count was at 20. Lactate has been 3.7, with am labs\n pending.\n Plan:\n Abx as ordered, f/u on cultures\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on Vent CPAP, 40%, 10 PEEP, PS : 5.. On fent @ 150 mcg/hr,\n Midaz 10 mg/hr.\n Action:\n . Fentanyl increased to 175 mcg/hr & Midaz to 8 mg/hr for comfort .\n Weaned off sedation to 100 mcg/hr fentanyl & midaz 6 mg/hr. Vent\n parameter changed to PCV/ 80% /rate :30, PEEp : 12. . ABG sent X2.\n Last ABG 7.34/39/80 . Suctioned frequently for moderate white thin\n secretions. Bronchoscopy done at bedside, bronchial wash sent for\n analysis. ET tube rotated & retaped.\n Response:\n Satting at high 90\ns on PCV, desatted at high 80\ns & tachypnic when\n increased PEEP & other vent changes. Refer flowsheet for details.\n Overbreathing on vent at times @ 32-36 bpm.\n Plan:\n Wean FiO2 & vent parameters as tolerated. Repeat ABG as needed. Plan\n to place new A line ( as there is no back flow from the old one)\n Pneumonia, other\n Assessment:\n Lungs auscultation reveals : Bilat upper lobes rhonchi, bilat lower\n lobes : crackles. CXR done . WBC : 15.7\n Action:\n CXR shpws diffuse opacities, L>R , No effusion. On Levoflox &\n cephalosporin ( for CAP coverage). & Vanc IV empirically.\n Response:\n .SBP between 90-110 mm of hg.\n Plan:\n F/U Blood culture & BAL . Will cont on Bactrim ( for PCP),\n Cephalosporin & Levoflox ( For CAP coverage ) & VANCO empirically\n until data from BAL returns.\n Fever ( unknown origin)\n Assessment:\n T max : 102.9. WBC : 15.7\n Action:\n Tylenol 650 mg + 325 mg per OG tube given. Sponge bath given.\n Panculture sent.\n Response:\n Patient diaphoretic. Temp at 99.2.\n Plan:\n F/U culture & will cont Abx..\n Low urine output\n Assessment:\n Urine output ml/hr.\n Action:\n Urine sent for culture & legionella.m No fluid bolus given during\n this shift.\n Response:\n MD notified. No improvement noted.\n Plan:\n F/U with lab result. Cont monitoring Urine output.\n" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543897, "text": "Chief Complaint: Hypoxic resp 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 HPI: 41 F with history of asthma, recently initiated treatment for\n atypical pneumonia, now represents to ED for severe pneumonia and\n respiratory failure requiring intubation. Patient seen on for R\n sided chest pain, shortness of breath and cough. Discharged from ED on\n azithromycin after CXR showing atypical pneumonia. Normal O2 per ED\n notes from that visit. Did not improve at home and represented to ED\n yesterday evening. Per EMS report, O2 sat 65% upon their arrival.\n In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of\n hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L NS\n given, also vanc, levoflox, cefepime, bactrim. Tachypneic to 40-50s;\n intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8 70% FiO2 prior\n to arrival to floor.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 AM\n Other medications:\n Changes to medical and family history:\n PMH:\n asthma\n ?cutting behavior/depreesion (seen on exam).\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 86 mL\n PO:\n TF:\n IVF:\n 445 mL\n 86 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -404 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (507 - 624) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 36%\n PIP: 10 cmH2O\n SpO2: 95%\n ABG: 7.50/50/117/38/13\n Ve: 8.2 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: No(t) Symmetric), (Breath Sounds:\n Clear : )\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 574 K/uL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ) and we are going to wean steroids further as well as abx\n regiment\n - D/c ceftriaxone today, cont levaquin (and plan stop tomorrow)\n - Cont PS ventilation: SBT today.\n - Decrease to methylprednisolone 60 mg IV q 6h \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n - Goal net negative today (500 cc) she seems to be concentrated by labs\n - Hopeful for extubation today.\n >ETOH withdrawl / altered mental: she is less responsive this morning\n then previously although there is no focality to her exam. We will hold\n all sedating medications, would check head CT to r/o any interval\n change, there is no clear metabolic precipitant and we can check a ABG\n to rule out CO2 retention. Sub-clinincal status is also on the\n differential in the setting of her EtOH withdrawl and we can also check\n B12, TSH, RPR.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n - Hopeful for improved for mental status\n Coagulopathy: elevated INR, probably related in some part to cirrhosis\n and nutritional deficiency. We will trial three days of Vitamin K.\n Other issues per ICU resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543902, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n CT head (-) for bleed or focal pathology -\"no change since \"\n TSH/B12/RPR added-on for mental status changes\n Steroids tapered to 60mg q6\n Stopped ceftriaxone, continued levofloxacin\n Extubation - 4pm - received 0.2mg x2 flumazenil for somnolence post\n extubation\n Lasix 20mg iv x1\n NGT placed, lactulose started\n Showed progressive neurological improvement through evening, but\n continued difficulty following commands\n ~1215 am - ~50cc coffee ground emeis post dry heaving. NG lavage\n performed with ~250cc water, ~150 returned with no e/o of blood. Stat\n hct stable at 32 and 31. Stopped famotidine, started iv protonix,\n cross matched 2uPRBCs.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 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 07:51 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 88 mL\n PO:\n TF:\n IVF:\n 445 mL\n 88 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (507 - 624) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 36%\n PIP: 10 cmH2O\n SpO2: 95%\n ABG: 7.50/50/117/38/13\n Ve: 8.2 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\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: )\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 574 K/uL\n 10.6 g/dL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ASTHMA\n .H/O DEPRESSION\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\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" }, { "category": "Physician ", "chartdate": "2125-10-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543905, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:36 PM\n CT head (-) for bleed or focal pathology -\"no change since \"\n TSH/B12/RPR added-on for mental status changes\n Steroids tapered to 60mg q6\n Stopped ceftriaxone, continued levofloxacin\n Extubation - 4pm - received 0.2mg x2 flumazenil for somnolence post\n extubation\n Lasix 20mg iv x1\n NGT placed, lactulose started\n Showed progressive neurological improvement through evening, but\n continued difficulty following commands\n ~1215 am - ~50cc coffee ground emeis post dry heaving. NG lavage\n performed with ~250cc water, ~150 returned with no e/o of blood. Stat\n hct stable at 32 and 31. Stopped famotidine, started iv protonix,\n cross matched 2uPRBCs.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 09:36 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 11:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Furosemide (Lasix) - 03:30 PM\n Famotidine (Pepcid) - 08:28 PM\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Pantoprazole (Protonix) - 01:20 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 07:51 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: 61 (53 - 101) bpm\n BP: 167/86(105) {119/61(75) - 181/93(113)} mmHg\n RR: 13 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (8 - 20)mmHg\n Total In:\n 565 mL\n 88 mL\n PO:\n TF:\n IVF:\n 445 mL\n 88 mL\n Blood products:\n Total out:\n 3,345 mL\n 490 mL\n Urine:\n 3,345 mL\n 470 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -2,780 mL\n -402 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 624 (507 - 624) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 36%\n PIP: 10 cmH2O\n SpO2: 95%\n ABG: 7.50/50/117/38/13\n Ve: 8.2 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\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: )\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 574 K/uL\n 10.6 g/dL\n 168 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.8 mEq/L\n 37 mg/dL\n 103 mEq/L\n 145 mEq/L\n 31.1 %\n 15.8 K/uL\n [image002.jpg]\n 04:44 AM\n 04:54 AM\n 03:29 PM\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n WBC\n 17.4\n 15.7\n 15.8\n Hct\n 28.6\n 31.3\n 32.2\n 31.1\n Plt\n \n Cr\n 0.7\n 0.6\n 0.6\n 0.6\n 0.7\n TCO2\n 34\n 40\n 40\n Glucose\n 111\n 172\n 187\n 183\n 163\n 168\n Other labs: PT / PTT / INR:15.7/24.1/1.4, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/15, Alk Phos / T Bili:80/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.2 g/dL, LDH:514 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia\n clinically improving, lung mechanics/rsbi robust.\n C/w noninfectious cause, +eosinophilia, ?AEP.\n - decrease solumedrol 60 Q6hrs ()\n - IgE pending (can be suggestive of AEP), ANCA (? vasculitis)\n - f/u cxs\n - cont levoflox to complete tentative 10d course , DC ceftriaxone\n # Respiratory failure\n required intubation for pna/pneumonitis. Lung\n mechanics passing sbt with adequate cough and gag. Weaning and\n extubation limited by secretions and mental status.\n - hold versed\n - (-)500cc to 1L today\n - post CT head today, plan for extubation\n # mental status changes\n med effect, epilecticus (although no PE\n findings or hemodynamic changes).\n - ct head r/o bleed (no focality to exam)\n - b12, folate, tsh, rpr\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal once extubated and off versed. Benzos prn.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\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" }, { "category": "Respiratory ", "chartdate": "2125-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543052, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 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: Standard\n Size: 7.5mm\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: White / Thick\n Sputum source/amount: Suctioned / Moderate\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 remains on current vent settings. See vent flow sheet for\n details. Temp 99.4. No RSBI done on 12 of peep. Sedated with fentanyl\n and midazolam.Anxious when awake.Will cont to monitor resp status.\n" }, { "category": "Respiratory ", "chartdate": "2125-10-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543226, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\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: 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 / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Intercostal retractions\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: reduce peep overnight to 8cmh20 by\n am.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1700\n no complicatins\n Bedside Procedures:\n Nasal aspiration (10:00)\n Comments:\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543060, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543324, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 539 mL\n PO:\n TF:\n 509 mL\n 225 mL\n IVF:\n 3,397 mL\n 264 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 436 K/uL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP ) and her WBC\n conts to rise in the setting of broad spectrum coverage. The Chest CT\n from shows a dramatic GGO and consolidation pattern in the upper\n lobes predominantly which could be consistent with AEP,PAP and possibly\n some volume overload (increased BNP on admission)\n - Empiric coverage as above\n - F/u viral studies: Ag pending\n - Cont PS ventilation\n - increase methylpred to 125 mg IV q 6h\n - Net neg fluid balance\n - Check IgE (add on to admit)\n Lactic acidosis/Increased renal failure: improvement in renal\n function and lactate. Will cont to trend.\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB, mouth care, daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543325, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 539 mL\n PO:\n TF:\n 509 mL\n 225 mL\n IVF:\n 3,397 mL\n 264 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 436 K/uL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP ) and her WBC\n conts to rise in the setting of broad spectrum coverage. The Chest CT\n from shows a dramatic GGO and consolidation pattern in the upper\n lobes predominantly which could be consistent with AEP,PAP and possibly\n some volume overload (increased BNP on admission)\n - Empiric coverage as above\n - F/u viral studies: Ag pending\n - Cont PS ventilation\n - increase methylpred to 125 mg IV q 6h\n - Net neg fluid balance\n - Check IgE (add on to admit)\n Lactic acidosis/Increased renal failure: improvement in renal\n function and lactate. Will cont to trend.\n ETOH withdrawl: on midazolam, may need CIWA and haldol in the\n extubation setting.\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB, mouth care, daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "Nutrition", "chartdate": "2125-10-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 542922, "text": "Subjective\n unable to assess\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 82 kg\n 30\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 145\n 63 kg *\n Diagnosis: PNA\n PMH : asthma, depression\n Food allergies and intolerances: NKFA\n Pertinent medications: fent gtt, versed gtt, NS @ 10ml/hr, Abx,\n Famotidine, Heparin, MVI, Solumedrol, CaGluconate (2gm), Neutraphos (2\n packets)\n Labs:\n Value\n Date\n Glucose\n 203 mg/dL\n 05:17 AM\n BUN\n 12 mg/dL\n 05:17 AM\n Creatinine\n 0.5 mg/dL\n 05:17 AM\n Sodium\n 136 mEq/L\n 05:17 AM\n Potassium\n 3.9 mEq/L\n 05:17 AM\n Chloride\n 108 mEq/L\n 05:17 AM\n TCO2\n 21 mEq/L\n 05:17 AM\n PO2 (arterial)\n 74 mm Hg\n 10:36 AM\n PCO2 (arterial)\n 35 mm Hg\n 10:36 AM\n pH (arterial)\n 7.40 units\n 10:36 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 10:36 AM\n Calcium non-ionized\n 6.7 mg/dL\n 05:17 AM\n Phosphorus\n 2.5 mg/dL\n 05:17 AM\n Magnesium\n 1.8 mg/dL\n 05:17 AM\n ALT\n 13 IU/L\n 05:17 AM\n Alkaline Phosphate\n 95 IU/L\n 05:17 AM\n AST\n 24 IU/L\n 05:17 AM\n Total Bilirubin\n 0.2 mg/dL\n 05:17 AM\n WBC\n 15.7 K/uL\n 05:17 AM\n Hgb\n 8.9 g/dL\n 05:17 AM\n Hematocrit\n 27.1 %\n 05:17 AM\n Current diet order / nutrition support: DIET: NPO\n GI: soft, hypoactive bs\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 per adjusted body wt o 63kg *\n Calories: 1260-1575 (BEE x or / 20-25 cal/kg)\n Protein: 76-88 (1.2-1.4 g/kg)\n Fluid: team\n Estimation of previous intake:\n Estimation of current intake: Inadequate NPO\n Specifics:\n 41 y/o female admitted w/ R pectoral pain 2 days ago. Pt given Abx for\n PNA and sent home. Pt readmitted w/ SOB. Found to have severe PNA\n ?infectious source; intubated for respiratory distress. Consulted for\n TF recs; pt w/ OGT. Noted low Ca, Phos; elevated BS.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: cont NPO\n Multivitamin / Mineral supplement: continue outside MVI\n Tube feeding recommendations:\n 1. Rec Nutren Pulmonary @ 10ml/hr, advance as tolerated to goal\n of 40ml/hr\n 2. Rec add 15g Beneprotein to TF; total = 1494calories and 78g\n protein]\n 3. Check residuals, hold TF if >/= 200ml\n Check chemistry 10 panel daily\n please check ionized Ca\n Replete lytes prn\n BS mgmt\n Will follow\n page if ?s *\n" }, { "category": "Physician ", "chartdate": "2125-10-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 542927, "text": "Chief Complaint: hypoxic respiratory failure\n HPI:\n 41 F with history of asthma, recently initiated treatment for atypical\n pneumonia, now represents to ED for severe pneumonia and respiratory\n failure requiring intubation. Patient seen on for R sided chest\n pain, shortness of breath and cough. Discharged from ED on\n azithromycin after CXR showing atypical pneumonia. Normal O2 per ED\n notes from that visit. Did not improve at home and represented to ED\n yesterday evening. Per EMS report, O2 sat 65% upon their arrival.\n Further history unknown at this time.\n In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of\n hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L NS\n given, also vanc, levoflox, cefepime, bactrim. Tachypneic to 40-50s;\n intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8 70% FiO2 prior\n to arrival to floor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 03:47 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Other medications:\n MVI daily\n Prozac 60 mg daily\n Zithromax Zpack\n Percocet 1-2 tabs TID prn\n Past medical history:\n Family history:\n Social History:\n asthma\n ?cutting behavior/depreesion (seen on exam).\n unknown\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: unknown\n Review of systems:\n Cardiovascular: Chest pain\n Respiratory: Cough, Dyspnea, Wheeze\n Flowsheet Data as of 05:29 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: 84 (84 - 92) bpm\n BP: 102/68(81) {102/68(81) - 102/68(81)} mmHg\n RR: 25 (25 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 5,872 mL\n PO:\n TF:\n IVF:\n 522 mL\n Blood products:\n Total out:\n 0 mL\n 220 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,652 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 300 (300 - 300) mL\n RR (Set): 26\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n Compliance: 80 cmH2O/mL\n SpO2: 98%\n Ve: 11.7 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, on vent\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, No(t) Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), distant\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: Bronchial:\n , No(t) Wheezes : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice. RUE well healed\n horizontal scars.\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed, follows commands\n when not sedated\n Labs / Radiology\n 442\n 11.3\n 99\n 0.6\n 11\n 24\n 103\n 3.6\n 138\n 32.7\n 15.1\n [image002.jpg]\n Other labs: PT / PTT / INR://1.1, CK / CKMB / Troponin-T://<0.01,\n Differential-Neuts:85, Lymph:11, Eos:0.4, LDH:740\n Imaging: CXR: widespread diffuse airspace opacities, most prominent\n bilateral hila, L>R. No effusion. ETT in satisfactory position.\n .\n Bronch (urgent in ED): normal limited airway exam. RML BAL done.\n Microbiology: blood cultures pending\n ECG: ECG: NSR at 94. NANI. No ST segment changes. No significant\n interval change.\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent.\n #Community acquired pneumonia. Initiated treatment for pneumonia 2\n days PTA with azithromycin but did not improve. Patient with\n widespread pulmonary infiltrates, leukocytosis, mildly elevated temps.\n Significant O2 requirement as below. Patient with history of asthma,\n no on steroids or other known immunosuppressants; no known risk factors\n for unusual organisms (fungals: histo/blasto, coccidio; PCP have\n elevated LDH) though little is known about her history and risk factors\n for these diseases. Also consider usual CAP organisms, staph,\n legionella. Noninfectious pneumonia also a possibility (AEP, AIP),\n alveolar hemorrhage less likely given appearance of BAL fluid.\n - BAL for cell count pending.\n - Also checking PCP stain, fungal cultures, AFB, rapid respiratory\n viral, legionella, cytology of BAL.\n - urine legionella Ag.\n - Cover for severe CAP coverage (levoflox + cephalosporin). Will\n continue vanc in addition empirically until data from BAL returns;\n Bactrim for PCP treatment plus steroids (pred 40 )\n - Monitor hemodynamics, no evidence of hypotension/shock thus far. If\n so, definitely needs CVL.\n - Collateral info from family.\n .\n # Respiratory failure. Requiring intubation. Now on ARDSnet volumes,\n currently at FiO2 0.7-1.0 and PEEP 8.\n - ARDSnet ventilation. Increase PEEP (start with 12) and try to\n decrease FiO2.\n - versed/fent\n - CXR daily\n - VAP precautions.\n - Daily wake up.\n .\n # Depression. continue home prozac dose.\n ICU Care\n Nutrition: NPO, tube feeding recs.\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:03 AM\n Arterial Line - 04: CVL today for improved CVP monitoring.\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "2125-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542997, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n 11/10with SOB with sat of 65% on room air and RR in the 30-40's. LS\n w/scattered rhonchi, placed on 100% NRB. Anxious with increasing WOB.\n Was intubated with etomidate and succs. Difficult to sedate, briefly\n paralyzed. Eventually settled on fentanyl and versed gtts. Abg\n 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings sent. Received\n cefepime, levoflox, and vanco. Blood cx's sent. Leukocytosis. Has\n received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. Patient\ns daughter called twice for\n status.& gave her contact no. ( : H : , C :\n )\n Significant Events on : **** Central line placement : RIJ, CVP\n 9-16 .\n ***** Bronchoscopy done .\n **** Pan culture sent ( temp :102.9)\n ***** Vigilleo monitor connected , CI 2.0-2.8.\n ***** Bronchial lavage sent for analysis.\n ***** Tube feeding started.\n **** Vent parameter changed . ABG repeated X2\n **** Cal gluconate 2 gm IV & Neutra phos 2 pck given.\n ***** ET tube rotated & retaped at 21 cm at lip.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on Vent AC/100%/RR :26/ PEEP : 8,/TV 400. On fent @ 100\n mcg/hr, Midaz 5 mg/hr. Require frequent suctioning.\n Action:\n Requiring frequent bolus sedation . Fentanyl increased to 175 mcg/hr\n & Midaz to 8 mg/hr for comfort . Weaned off sedation to 100 mcg/hr\n fentanyl & midaz 6 mg/hr. Vent parameter changed to PCV/ 80% /rate :30,\n PEEp : 12. . ABG sent X2. Last ABG 7.34/39/80 . Suctioned frequently\n for moderate white thin secretions. Bronchoscopy done at bedside,\n bronchial wash sent for analysis. ET tube rotated & retaped.\n Response:\n Satting at high 90\ns on PCV, desatted at high 80\ns & tachypnic when\n increased PEEP & other vent changes. Refer flowsheet for details.\n Overbreathing on vent at times @ 32-36 bpm.\n Plan:\n Wean FiO2 & vent parameters as tolerated. Repeat ABG as needed. Plan\n to place new A line ( as there is no back flow from the old one)\n Pneumonia, other\n Assessment:\n Lungs auscultation reveals : Bilat upper lobes rhonchi, bilat lower\n lobes : crackles. CXR done . WBC : 15.7\n Action:\n CXR shpws diffuse opacities, L>R , No effusion. On Levoflox &\n cephalosporin ( for CAP coverage). & Vanc IV empirically.\n Response:\n .SBP between 90-110 mm of hg.\n Plan:\n F/U Blood culture & BAL . Will cont on Bactrim ( for PCP),\n Cephalosporin & Levoflox ( For CAP coverage ) & VANCO empirically\n until data from BAL returns.\n Fever ( unknown origin)\n Assessment:\n T max : 102.9. WBC : 15.7\n Action:\n Tylenol 650 mg + 325 mg per OG tube given. Sponge bath given.\n Panculture sent.\n Response:\n Patient diaphoretic. Temp at 99.2.\n Plan:\n F/U culture & will cont Abx..\n Low urine output\n Assessment:\n Urine output ml/hr.\n Action:\n Urine sent for culture & legionella.m No fluid bolus given during\n this shift.\n Response:\n MD notified. No improvement noted.\n Plan:\n F/U with lab result. Cont monitoring Urine output.\n" }, { "category": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543148, "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 BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Crackles : , Rhonchorous: but\n improved compared to yesterday)\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 9.0 g/dL\n 379 K/uL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n BAL: PCP neg, gram stain and clx neg\n CXR: marked improvement in the airspace disease process from\n previous\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Her PCP on BAL was negative, though she did have a\n markedly increased LDH. In addition, we will cover with Vanco, CTX\n ,Azithro. Notably, her plateau pressures are not consistent with ARDS,\n there is no evidence of bleeding which would go for DAH, the cell count\n now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process\n - Empiric coverage as above\n - F/u viral\n - Cont PS ventilation\n - Chest CT to further evaluate\n Lactic acidosis/Increased renal failure: lactate 3.7, no clear\n etiology, Creatinine has doubled over the past 24. ? bactrim toxicity,\n renal toxicity. Stopped bactrim, Will check vanco level and Urine\n lytes and osm\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Insuliun infusion\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543221, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PCV with RR set @30, fio2 40%, Peep +12. Overbreathing\n 34-40. Tv\ns 200-600cc\ns. Sats 93-96%. Ls rhoncherous throughout. Strong\n cough with small amount white thick sputum. CXR from the afternoon of\n showed diffuse b/l opacities but improved over previous day\n however, this am xray was much improved.\n Action:\n Since pt appeared very uncomfortable on the vent sedation was increased\n to 150mcgs of fent and 10 mg of versed. PT WAS CHANGED TO ps OF 5 AND\n PEEP OF 12 with an fio2 of 40%. Pt ABG was much improved with those\n settings so we were able to wean to peep to 10 with the hopes of having\n pt extubated in am.\n Response:\n Please see Metavision for ABG\nS. Pt seems to do better with the PS. Of\n note pt is a long time smoker of 1 ppd and is a heavy drinker with a\n history of withdraws per the daughter. Pt also had a CT of the chest\n to further investigate the lungs and results are pending.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 99.8. moderate amounts of white thick sputum. NGTD\n on blood cx\ns, Bal washings and cx\ns. PCP and urine legionella have\n been R/O.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids.\n Response:\n Remains with low grade temps. Wbc continue raise last count was at 20.\n Lactate 3.7 this morning.\n Plan:\n Abx as ordered, f/u on cultures.\n" }, { "category": "Respiratory ", "chartdate": "2125-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543282, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\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: 4 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: White / 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: Accessory muscle use, High flow\n demand; Comments: Low RR 7-9, with Vt of 700-1000\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n Comments:\n Pt is on high levels of fentenyl and sedation. She may have ETOH\n dependency. Lungs are very course with rales or rhonchi in most areas.\n" }, { "category": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543168, "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 BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: (Breath Sounds: Crackles : , Rhonchorous: but\n improved compared to yesterday)\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 9.0 g/dL\n 379 K/uL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n BAL: PCP neg, gram stain and clx neg\n CXR: marked improvement in the airspace disease process from\n previous\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Her PCP on BAL was negative, though she did have a\n markedly increased LDH. In addition, we will cover with Vanco, CTX\n ,Azithro. Notably, her plateau pressures are not consistent with ARDS,\n there is no evidence of bleeding which would go for DAH, the cell count\n now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process\n - Empiric coverage as above\n - F/u viral\n - Cont PS ventilation\n - Chest CT to further evaluate\n Lactic acidosis/Increased renal failure: lactate 3.7, no clear\n etiology, Creatinine has doubled over the past 24. ? bactrim toxicity,\n renal toxicity. Stopped bactrim, Will check vanco level and Urine\n lytes and osm\n ID: as above and will also follow up blood cx\n Addendum- consider d/c Abx gradually and decreasing steroids to\n equivalent dose 1mg/kg/day of prednisone.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Insuliun infusion\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543524, "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 > did well on PS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/81(100)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 156 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 152 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,784 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 910 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 6.5 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : diffusely, Rhonchorous\n but less then yesterday: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic:, Responds to: Verbal stimuli, not following commande\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 484 K/uL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Rapid Respiratory Viral Antigen Test (Final ):\n Respiratory viral antigens not detected.\n SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND\n RSV.\n CXR : poor quality film, ? increasing effusion.\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ). Hopefuil\n - Will stop Vancomycin today, cont ceftriax/levaquin.\n - Cont PS ventilation: SBT today.\n - increase methylpred to 125 mg IV q 6h and will decrease on\n \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n >ETOH withdrawl / altered: on midazolam, may need CIWA and haldol in\n the extubation setting as her mental status is likely to be worsened in\n the setting of high dose steroids.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543117, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n - Switched to pressure controlled ventillation with improvement of\n oxygenation\n - Right IJ placed\n - Bronch showed more purluent secretions\n - PCP negative\n glucan/galactomannan pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\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 379 K/uL\n 9.0 g/dL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent.\n #Community acquired pneumonia. Initiated treatment for pneumonia 2\n days PTA with azithromycin but did not improve. Patient with\n widespread pulmonary infiltrates, leukocytosis, mildly elevated temps.\n Significant O2 requirement as below. Patient with history of asthma,\n no on steroids or other known immunosuppressants; no known risk factors\n for unusual organisms (fungals: histo/blasto, coccidio; PCP have\n elevated LDH) though little is known about her history and risk factors\n for these diseases. Also consider usual CAP organisms, staph,\n legionella. Noninfectious pneumonia also a possibility (AEP, AIP),\n alveolar hemorrhage less likely given appearance of BAL fluid.\n - BAL for cell count pending.\n - Also checking PCP stain, fungal cultures, AFB, rapid respiratory\n viral, legionella, cytology of BAL.\n - urine legionella Ag.\n - Cover for severe CAP coverage (levoflox + cephalosporin). Will\n continue vanc in addition empirically until data from BAL returns;\n Bactrim for PCP treatment plus steroids (pred 40 )\n - Monitor hemodynamics, no evidence of hypotension/shock thus far. If\n so, definitely needs CVL.\n - Collateral info from family.\n .\n # Respiratory failure. Requiring intubation. Now on ARDSnet volumes,\n currently at FiO2 0.7-1.0 and PEEP 8.\n - ARDSnet ventilation. Increase PEEP (start with 12) and try to\n decrease FiO2.\n - versed/fent\n - CXR daily\n - VAP precautions.\n - Daily wake up.\n .\n # Depression. continue home prozac dose.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Chief Complaint: respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,352 mL\n PO:\n TF:\n 80 mL\n 153 mL\n IVF:\n 2,734 mL\n 1,199 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 932 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\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 379 K/uL\n 9.0 g/dL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ASTHMA\n .H/O DEPRESSION\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543118, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n - Switched to pressure controlled ventillation with improvement of\n oxygenation\n - Right IJ placed\n - Bronch showed more purluent secretions\n - PCP negative\n glucan/galactomannan pending\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\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 379 K/uL\n 9.0 g/dL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent.\n #Community acquired pneumonia. Initiated treatment for pneumonia 2\n days PTA with azithromycin but did not improve. Patient with\n widespread pulmonary infiltrates, leukocytosis, mildly elevated temps.\n Significant O2 requirement as below. Patient with history of asthma,\n no on steroids or other known immunosuppressants; no known risk factors\n for unusual organisms (fungals: histo/blasto, coccidio; PCP have\n elevated LDH) though little is known about her history and risk factors\n for these diseases. Also consider usual CAP organisms, staph,\n legionella. Noninfectious pneumonia also a possibility (AEP, AIP),\n alveolar hemorrhage less likely given appearance of BAL fluid.\n - BAL for cell count pending.\n - Also checking PCP stain, fungal cultures, AFB, rapid respiratory\n viral, legionella, cytology of BAL.\n - urine legionella Ag.\n - Cover for severe CAP coverage (levoflox + cephalosporin). Will\n continue vanc in addition empirically until data from BAL returns;\n Bactrim for PCP treatment plus steroids (pred 40 )\n - Monitor hemodynamics, no evidence of hypotension/shock thus far. If\n so, definitely needs CVL.\n - Collateral info from family.\n .\n # Respiratory failure. Requiring intubation. Now on ARDSnet volumes,\n currently at FiO2 0.7-1.0 and PEEP 8.\n - ARDSnet ventilation. Increase PEEP (start with 12) and try to\n decrease FiO2.\n - versed/fent\n - CXR daily\n - VAP precautions.\n - Daily wake up.\n .\n # Depression. continue home prozac dose.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543459, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine. Known h/o\n asthma and depression as well as a pint and a half of alcohol a day per\n Pt\ns daughter.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt.. continues on moderate amt\ns of sedation. Pt. continues to sit\n upright in the bed\n Action:\n Pt.\ns sedation has been weaned with plans to extubate pt. today.\n Response:\n Pt. continues to buck the ventilator from time to time. At present Pt.\n is resting comfortably.\n Plan:\n Plan remains to attempt extubation from ventilator. And continue to\n monitor signs of alcohol withdrawl.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PS 5/5 Peep, fio2 40%, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with moderate to large amt\ns of white thick\n sputum. CXR showed diffuse b/l opacities but improved over\n previous day .CT scan performed showed diffuse opacities\n throughout the lungs with chronic pancreatitis . No back flow from\n A-line, ABG pending.\n Action:\n sedation weaned down to 25mcgs of fent and 2.5 mg of versed. PT\n remains on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n .Pt seems comfortable with the PS. Of note pt is a long time smoker of\n 1 ppd and is a heavy drinker 91.5 pints /day) with a history of\n withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation if tolerated.. F/u on am\n CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous, improved after lasix 20 mg IV at 2300.. Tmax 99.1 ,\n moderate amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. Started on Solumedrol\n 125 mg Q 6 hr for high WBC count.\n Response:\n T max 99.1. Wbc remain elevated but have started to trend down.\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Hyperglycemia\n Assessment:\n FSBS 102-148.\n Action:\n Insulin gtt has now been shut off as off 0400 and pt. will resume on\n sliding scale insulin coverage..\n Response:\n Last FSBS 156 at 0600, up from 104 at 0400.\n Plan:\n Will cont q6hr FSBS\n" }, { "category": "Physician ", "chartdate": "2125-10-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543170, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 02:00 PM\n URINE CULTURE - At 02:00 PM\n MULTI LUMEN - START 02:00 PM\n BRONCHOSCOPY - At 02:40 PM\n SPUTUM CULTURE - At 02:40 PM\n ARTERIAL LINE - STOP 05:30 PM\n ARTERIAL LINE - START 06:45 PM\n FEVER - 102.9\nF - 12:00 PM\n - Switched to pressure controlled ventillation with improvement of\n oxygenation\n - Right IJ placed\n - Bronch showed more purluent secretions\n - PCP negative\n glucan/galactomannan pending\n BAL fluid with 12% eos (initial bronch in ED)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 PM\n Levofloxacin - 10:00 PM\n Bactrim (SMX/TMP) - 06:02 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:03 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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.4\nC (99.4\n HR: 104 (76 - 107) bpm\n BP: 117/62(79) {104/60(76) - 134/78(97)} mmHg\n RR: 35 (15 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 11 (8 - 17)mmHg\n Total In:\n 8,314 mL\n 1,349 mL\n PO:\n TF:\n 80 mL\n 152 mL\n IVF:\n 2,734 mL\n 1,198 mL\n Blood products:\n Total out:\n 750 mL\n 420 mL\n Urine:\n 750 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,564 mL\n 929 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.37/32/86./18/-5\n Ve: 15.9 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General: Intubated/sedated but arouses to voice, follows simple\n commands with all extremities.\n HEENT; ETT/OGT in place. MMM. PERRL.\n Neck: RIJ site benign.\n Chest: Very rhoncherous/coarse bilaterally. Overall little change\n Heart: Regular, S1 S2 sligjhtly distant, no murmur appreciated.\n Abdomen: soft NT/ND.\n Extrem: warm, no edema.\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 379 K/uL\n 9.0 g/dL\n 318 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.4 mEq/L\n 16 mg/dL\n 100 mEq/L\n 132 mEq/L\n 26.6 %\n 16.6 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n 10:36 AM\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n WBC\n 15.7\n 16.6\n Hct\n 27.1\n 26.6\n Plt\n 348\n 379\n Cr\n 0.5\n 0.8\n TropT\n 0.04\n TCO2\n 22\n 22\n 22\n 20\n 19\n Glucose\n 203\n 318\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:, Alk Phos\n / T Bili:85/0.1, Lactic Acid:3.7 mmol/L, Albumin:2.8 g/dL, LDH:744\n IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n CXR today: poor qualitiy, but appears to show significant improvement\n in bilat opacities.\n BAL: notable for 12% eos on first BAL; second with !% eos.\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia. Initiated treatment for pneumonia 2 days PTA with\n azithromycin but did not improve. widespread pulmonary infiltrates,\n leukocytosis, mildly elevated temps, significant O2 requirement and\n vent support. Now clinically improving with requirement for less vent\n and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest AEP. PCP and legionella negative.\n - Continue steroids (initially on for PCP treatment with bactrim, will\n continue for presumptive diagnosis of AEP.\n - follow BAL cultures.\n - check chest CT today; still with abnormal exam\n - rapid viral insufficient; will resend with ETT aspirate.\n - For now will continue coverage for severe CAP coverage (levoflox +\n cephalosporin and vancomycin). D/c bactrim, as BAL fluid negative.\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2.\n - Try decrease PEEP to 10 this AM, can go down to 8 if PaO2 tolerates.\n - versed/fent with daily wake up\n - CXR daily\n - VAP precautions.\n - Hope for extubation as early as tomorrow given improvement.\n # Lactic acidosis. >3 this AM, no priors. HD stable, no hypotension\n or e/o hypoperfusion.\n - recheck and monitor hemodynamics.\n # Renal function. Creatinine within normal limits but significant bump\n since admission.\n - recheck this PM.\n - Check urine eos.\n - Stopping bactrim as above ?offending .\n - Check vanc level\n - Urine lytes\n # hyponatremia. Suspect iatrogenic as getting multiple high volume\n meds in D5W.\n - stopping bactrim as above\n - recheck this afternoon.\n - Urine NA and osms.\n .\n # Depression. continue home prozac dose.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "Case Management ", "chartdate": "2125-10-22 00:00:00.000", "description": "Case Managment Initial Patient Assessment", "row_id": 542917, "text": "Insurance information\n Primary insurance: MASSHEALTH MANAGED CARE\n Secondary insurance: SELF PAY\n Insurance reviewer::n/a\n Free Care application: No\n Status: Referred\n Medicaid application: N/A\n Pre-Hospitalization services: none\n DME / Home O[2]: no\n Functional Status / Home / Family Assessment:\n lives w mom \n Primary Contact(s):\n Health Care Proxy: Deferred.\n Dialysis: No\n Referrals Recommended: Physical Therapy\n Current plan: Home\n re-eval after inital w/u\n Patient (s) to Discharge:\n intub/vent\n Patient discussed with multidisciplinary team: No\n" }, { "category": "Respiratory ", "chartdate": "2125-10-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543460, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 4 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: White / Thin\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: Supra-sternal retractions,\n Accessory muscle use, Gasping efforts, High flow demand; Comments: No\n tachypnea, RR is very low, high flow demand may be due to\n non-repiratory causes, ie neuro, substance WD\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Probably extubation today.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments:\n RSBI ~ 20 this morning. ABG sows good oxygenation with elevated Pco2\n which is compensating for metabolic alkalosis\n" }, { "category": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543462, "text": "Chief Complaint: pneumonia\n 24 Hour Events:\n - Weaned to and tolerated well. Trying to wean sedation for plan\n for extubation today.\n - Rapid viral screen negative.\n - Radiology recommends renal ultrasound for complex cyst seen\n incidentally.\n - Lasix 20 IV x 2; even at midnight but -1.7 L by 5 am.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/96(103)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 144 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 140 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,796 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 796 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 7.4 L/min\n PaO2 / FiO2: 250\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)\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: )\n Abdominal: Soft, Non-tender\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 484 K/uL\n 9.3 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ASTHMA\n .H/O DEPRESSION\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Comments: NPO for extubation; insulin gtt off and starting scale\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543463, "text": "Chief Complaint: pneumonia\n 24 Hour Events:\n - Weaned to and tolerated well. Trying to wean sedation for plan\n for extubation today.\n - Rapid viral screen negative.\n - Radiology recommends renal ultrasound for complex cyst seen\n incidentally.\n - Lasix 20 IV x 2; even at midnight but -1.7 L by 5 am.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/96(103)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 144 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 140 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,796 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 796 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 7.4 L/min\n PaO2 / FiO2: 250\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)\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: )\n Abdominal: Soft, Non-tender\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 484 K/uL\n 9.3 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumoniaNow clinically improving with requirement for less\n vent and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest ?AEP. No peripheral eosinophilia. Does have upper\n lobe predominance on CT.\n - Continue solumedrol 125 Q6 hours.\n - checking IgE (can be suggestive of AEP), ANCA (? vasculitis)\n - follow final BAL cultures.\n - For now will continue coverage for severe CAP coverage (levoflox +\n cephalosporin and vancomycin).\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2. Diuresed\n overnight.\n - Extubate today.\n - Diurese today to optimize pulmonary function\n 20 IV lasix now and\n goal negative 1+ liter.\n .\n # Depression. continue home prozac dose\n # Concern for EtOH abuse. Per family. Chronic pancreatitis per\n imaging. Last drink thought to be or .\n - Monitor for withdrawal once extubated and off versed.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: NPO for extubation; insulin gtt off and starting scale\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543468, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/81(100)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 156 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 152 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,784 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 910 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 6.5 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : diffusely, Rhonchorous:\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 484 K/uL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP ) and her WBC\n conts to rise in the setting of broad spectrum coverage. The Chest CT\n from shows a dramatic GGO and consolidation pattern in the upper\n lobes predominantly which could be consistent with AEP,PAP and possibly\n some volume overload (increased BNP on admission)\n - Empiric coverage as above\n - F/u viral studies: Ag pending\n - Cont PS ventilation\n - increase methylpred to 125 mg IV q 6h\n - Net neg fluid balance\n - Check IgE (add on to admit)\n Lactic acidosis/Increased renal failure: improvement in renal\n function and lactate. Will cont to trend.\n ETOH withdrawl: on midazolam, may need CIWA and haldol in the\n extubation setting.\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543474, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/81(100)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 156 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 152 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,784 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 910 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 6.5 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : diffusely, Rhonchorous:\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 484 K/uL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP ) and her WBC\n conts to rise in the setting of broad spectrum coverage. The Chest CT\n from shows a dramatic GGO and consolidation pattern in the upper\n lobes predominantly which could be consistent with AEP,PAP and possibly\n some volume overload (increased BNP on admission)\n - Empiric coverage as above\n - F/u viral studies: Ag pending\n - Cont PS ventilation\n - increase methylpred to 125 mg IV q 6h\n - Net neg fluid balance\n - Check IgE (add on to admit)\n Lactic acidosis/Increased renal failure: improvement in renal\n function and lactate. Will cont to trend.\n ETOH withdrawl: on midazolam, may need CIWA and haldol in the\n extubation setting.\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543483, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****Started on Solumedrol 125 mg IV Q6\n hrly..\n ***** Lasix 20 mg IV given X1, good response.\n **** Goal is neg 500 cc out.\n ***** Weaning off fentanyl first & midaz as tolerated .\n ***** Insulin drip started . Hourly Blood sugar.\n ***** Vent parameter changed . Weaning off vent if tolerated\n ***** Tube feeding being held since 1700 hrs for\n possible\n Extubation.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep5, PS 5, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with small to moderate amount white thick\n sputum. CXR showed diffuse b/l opacities but improved over\n previous day .CT scan performed showed diffuse opacities\n throughout the lungs with chronic pancreatitis . No back flow from\n A-line,\n Action:\n sedation weaned off to 50mcgs of fent and 5 mg of versed. PT remains\n on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n .Pt seems comfortable with the PS. Of note pt is a long time smoker of\n 1 ppd and is a heavy drinker 91.5 pints /day) with a history of\n withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation if tolerated.. F/u on am\n CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous, improved after lasix 20 mg IV. Tmax 99 , moderate\n amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc : 17.4.. Lactate : 1.0\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Hyperglycemia\n Assessment:\n FSBS ranges\n Action:\n Insulin\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543286, "text": "P/w right sided pectoral/lung pain 3 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine. Pt. went to\n CT for scan of chest late yesterday afternoon. Report remains pending.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PS with RR set @30, fio2 40%, Peep +10. Sats 93-96%. Ls\n rhoncherous throughout. Strong cough with small amount white thick\n sputum. CXR from the afternoon of showed diffuse b/l opacities\n but improved over previous day however, this am xray was much improved.\n Ct scan performed yesterday afternoon.\n Action:\n Vent sedation remains at 150mcgs of fent and 10 mg of versed. PT\n remains on PS OF 5 AND PEEP OF 12 with an fio2 of 40%. Pt ABG was much\n improved with those settings so we were able to wean to peep to 10 with\n the hopes of having pt extubated in am.\n Response:\n Please see Metavision for ABG\nS. Pt seems to do better with the PS. Of\n note pt is a long time smoker of 1 ppd and is a heavy drinker with a\n history of withdraws per the daughter. Pt also had a CT of the chest\n to further investigate the lungs and results are pending.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 97.8 moderate amounts of white thick sputum. NGTD\n on blood cx\ns, Bal washings and cx\ns. PCP and urine legionella have\n been R/O.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids.\n Response:\n Remains afebrile throughout this shift. Wbc remain elevated am labs\n are pending. last count was at 20. Lactate has been 3.7, with am labs\n pending.\n Plan:\n Abx as ordered, f/u on cultures.\n OGT advanced per xray and xray repeated to confirm placement. Tube\n feeds are infusing at goal rate of 40cc/hr with residuals <100cc/4hrs.\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543292, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 539 mL\n PO:\n TF:\n 509 mL\n 225 mL\n IVF:\n 3,397 mL\n 264 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.9 g/dL\n 436 K/uL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Her PCP on BAL was negative, though she did have a\n markedly increased LDH. In addition, we will cover with Vanco, CTX\n ,Azithro. Notably, her plateau pressures are not consistent with ARDS,\n there is no evidence of bleeding which would go for DAH, the cell count\n now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process\n - Empiric coverage as above\n - F/u viral\n - Cont PS ventilation\n - Chest CT to further evaluate\n Lactic acidosis/Increased renal failure: lactate 3.7, no clear\n etiology, Creatinine has doubled over the past 24. ? bactrim toxicity,\n renal toxicity. Stopped bactrim, Will check vanco level and Urine\n lytes and osm\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 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 :ICU\n Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543297, "text": "Chief Complaint:\n 24 Hour Events:\n Vanco, levo, ctx continued, bactrim discontinued\n CT chest: Diffuse ground glass opacities, worst in the upper lobes with\n possible crazy paving appearance. Dependent nodular opacities at the\n bases. Differential is broad and includes infectious and inflammatory\n etiologies such as pneumocystis pneumonia, pulmonary alveolar\n proteinosis, and noncardiac edema. Other less likely etiologies\n include bacterial pneumonia, chronic eosinophilic pneumonia,\n hypersensitivity pneumonitis and pulmonary hemorrhage. Extensive\n pancreatic calcifications.\n Family reported concern for ethanol withdrawal - ct showing chronic\n pancreatitis.\n NGT placement.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n FINGERSTICK GLUCOSE: 194-280 (since start of RISS)\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 562 mL\n PO:\n TF:\n 509 mL\n 236 mL\n IVF:\n 3,397 mL\n 276 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General:\n HEENT:\n Chest:\n Heart:\n Extrem:\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 436 K/uL\n 8.9 g/dL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia. Initiated treatment for pneumonia 2 days PTA with\n azithromycin but did not improve. widespread pulmonary infiltrates,\n leukocytosis, mildly elevated temps, significant O2 requirement and\n vent support. Now clinically improving with requirement for less vent\n and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest AEP. PCP and legionella negative.\n - Continue steroids (initially on for PCP treatment with bactrim, will\n continue for presumptive diagnosis of AEP.\n - follow BAL cultures.\n - check chest CT today; still with abnormal exam\n - rapid viral insufficient; will resend with ETT aspirate.\n - For now will continue coverage for severe CAP coverage (levoflox +\n cephalosporin and vancomycin). D/c bactrim, as BAL fluid negative.\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2.\n - Try decrease PEEP to 10 this AM, can go down to 8 if PaO2 tolerates.\n - versed/fent with daily wake up\n - CXR daily\n - VAP precautions.\n - Hope for extubation as early as tomorrow given improvement.\n # Lactic acidosis. >3 this AM, no priors. HD stable, no hypotension\n or e/o hypoperfusion. Now resolved.\n # Renal function. Creatinine within normal limits but significant bump\n yesterday, now improved. Stopped bactrim.\n .\n # Depression. continue home prozac dose\n ICU care\n NUtren pulmonary\n Insulin sliding scale\n H2 blocker\n PPI\n CVL and Aline\n Full code\n Dispo: ICU\n" }, { "category": "Nutrition", "chartdate": "2125-10-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 543513, "text": "Subjective\n unable to assess\n Objective\n Pertinent medications: Versed gtt, NS @ 10ml/hr, HISS, Famotidine, MVI,\n Abx, Solumedrol\n Labs:\n Value\n Date\n Glucose\n 111 mg/dL\n 04:44 AM\n Glucose Finger Stick\n 233\n 12:00 PM\n BUN\n 37 mg/dL\n 04:44 AM\n Creatinine\n 0.7 mg/dL\n 04:44 AM\n Sodium\n 141 mEq/L\n 04:44 AM\n Potassium\n 4.4 mEq/L\n 04:44 AM\n Chloride\n 102 mEq/L\n 04:44 AM\n TCO2\n 32 mEq/L\n 04:44 AM\n PO2 (arterial)\n 99. mm Hg\n 04:54 AM\n PCO2 (arterial)\n 48 mm Hg\n 04:54 AM\n pH (arterial)\n 7.44 units\n 04:54 AM\n pH (urine)\n 6.0 units\n 12:52 PM\n CO2 (Calc) arterial\n 34 mEq/L\n 04:54 AM\n Albumin\n 3.0 g/dL\n 04:44 AM\n Calcium non-ionized\n 8.7 mg/dL\n 04:44 AM\n Phosphorus\n 3.1 mg/dL\n 04:44 AM\n Ionized Calcium\n 1.18 mmol/L\n 01:23 PM\n Magnesium\n 2.1 mg/dL\n 04:44 AM\n ALT\n 20 IU/L\n 04:44 AM\n Alkaline Phosphate\n 83 IU/L\n 04:44 AM\n AST\n 25 IU/L\n 04:44 AM\n Total Bilirubin\n 0.2 mg/dL\n 04:44 AM\n WBC\n 17.4 K/uL\n 04:44 AM\n Hgb\n 9.3 g/dL\n 04:44 AM\n Hematocrit\n 28.6 %\n 04:44 AM\n Current diet order / nutrition support: DIET: NPO\n TF: OFF (Nutren Pulmonary @ 40ml/hr +15g Beneprotein)\n GI: soft, (+) bs\n Assessment of Nutritional Status\n Estimation of previous intake: adequate\n Estimation of current intake: inadequate d/t NPO\n Specifics:\n Pt admitted w/ PNA. TF started for nutrition support. Pt was\n tolerating TF @ goal, held at MN for possible extubation today.\n Insulin gtt was on high dose steroids, insulin gtt off now, however\n pt w/ elevated FSBG.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: cont NPO\n 1. If unable to extubate, rec resume TF for nutrition support\n 2. If able to extubate and pt w/ good MS, intact gag\n rec begin\n po diet (may need controlled diet pending BS)\n 3. If any concerns w/ swallowing ability\n please consult SLP for\n S+S evaluation\n Check chemistry 10 panel\n BS mgmt\n rec tighten SS\n Will follow\n page if ?s *\n" }, { "category": "Nursing", "chartdate": "2125-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542901, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n 11/10with SOB with sat of 65% on room air and RR in the 30-40's. LS\n w/scattered rhonchi, placed on 100% NRB. Anxious with increasing WOB.\n Was intubated with etomidate and succs. Difficult to sedate, briefly\n paralyzed. Eventually settled on fentanyl and versed gtts. Abg\n 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings sent. Received\n cefepime, levoflox, and vanco. Blood cx's sent. Leukocytosis. Has\n received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. Mother is . MD will need to speak\n with mother for consent and further history if known.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on Vent AC/100%/RR :26/ PEEP : 8,/TV 400. On fent @ 100\n mcg/hr, Midaz 5 mg/hr.\n Action:\n Requiring bolus sedation before suctioning & turning.\n Response:\n Satting at high 90\ns. Overbreathing on vent at times @ 28-30 bpm.\n Plan:\n Wean FiO2 as tolerated.\n Pneumonia, other\n Assessment:\n Lungs auscultation reveals : Bilat upper lobes rhonchi, bilat lower\n lobes : crackles. CXR done . WBC : 15.7\n Action:\n CXR shpws diffuse opacities, L>R , No effusion. On Levoflox &\n cephalosporin ( for CAP coverage). & Vanc IV empirically.\n Response:\n Afebrile. Art SBP between 90-110 mm of hg.\n Plan:\n F/U Blood culture & BAL . Will cont on Bactrim ( for PCP),\n Cephalosporin & Levoflox ( For CAP coverage ) & VANC empirically until\n data from BAL returns.\n" }, { "category": "Physician ", "chartdate": "2125-10-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 542911, "text": "Chief Complaint: Shortness of breath\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 41 yo with hx of ?asthma, recently seen in the ED and prescribed a\n Z-pak which she took. She became progressively dyspneic, with cough and\n malaise. Progressively worse at home, O2 sat of 65% at home with EMT.\n She received 5L of NS for transient hypotensive and received\n Vancomycin, levocfloxacin, Cefepime and Bactrim (PCP tx dose). She was\n intubated for hypox resp failure. Dr. reports on bronch it was a\n clear bronch with clear fluid returned and no purulence in the airways.\n She\n Patient admitted from: ER\n History obtained from Medical records, house officer\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 03:47 AM\n Ceftriaxone - 07:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Anxiety/Depression\n Self mutilatory behavior\n non contrib\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: unknown social histry\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 10:20 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: 36.2\nC (97.2\n HR: 92 (84 - 93) bpm\n BP: 104/64(78) {94/60(72) - 106/68(81)} mmHg\n RR: 27 (27 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,215 mL\n PO:\n TF:\n IVF:\n 865 mL\n Blood products:\n Total out:\n 0 mL\n 311 mL\n Urine:\n 311 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,904 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 947 (300 - 947) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 80%\n RSBI: 67\n PIP: 26 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 99%\n ABG: 7.36/37/142/21/-3\n Ve: 11.8 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: OG tube\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: (Breath Sounds: Crackles : diffusely, Diminished:\n bases, Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n 348 K/uL\n 27.1 %\n 8.9 g/dL\n 203 mg/dL\n 0.5 mg/dL\n 12 mg/dL\n 21 mEq/L\n 108 mEq/L\n 3.9 mEq/L\n 136 mEq/L\n 15.7 K/uL\n [image002.jpg]\n 05:17 AM\n 05:25 AM\n WBC\n 15.7\n Hct\n 27.1\n Plt\n 348\n Cr\n 0.5\n TropT\n 0.04\n TC02\n 22\n Glucose\n 203\n Other labs: CK / CKMB / Troponin-T:85//0.04, ALT / AST:13/24, Alk Phos\n / T Bili:95/0.2, LDH:576 IU/L, Ca++:6.7 mg/dL, Mg++:1.8 mg/dL, PO4:2.5\n mg/dL\n Fluid analysis / Other labs: BAL fluid count.\n Microbiology: BAL pending .\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure with\n Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status at this point but\n with her elevated LDH we are suspcious for PCP. cont to cover\n broadly at this point for CAP as well as PCP (including steroids). In\n addition, we will cover with Vanco, levoflox and azithro pending the\n results of the BAL.\n Her plateau pressures are not consistent with ARDS, there is no\n evidence of bleeding which would go for DAH, we will await the cell\n count to eval for evidence of eosinophilic PNA. Would favor placing\n - Empiric coverage as above\n - increase PEEP to 12 cm and recheck\n ID: as above and will also follow up blood cx\n ICU Care\n Nutrition:\n Comments: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 04:03 AM\n Arterial Line - 04:53 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: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543580, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****SBT for aprox 4 hours. Tolerated\n well.\n **** Back to vent on CPAP/40%/ PEEP :5, PS :5\n *** Suctioned for White frothy thin secretion frequently.\n **** Held extubation for increased secretion & mental status.\n **** Possible extubation .\n **** Weaning off fentanyl .\n ***** Midaz @ low dose (2.5 mg/hr)\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep5, PS 5, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with small to moderate amount white thick\n sputum. CT scan performed showed diffuse opacities throughout\n the lungs with chronic pancreatitis . No back flow from A-line & A\n line D/C\nd .\n Action:\n Fent weaned off completely and midaz @ 2.5 mg/hr . Back to vent\n with PS OF 5 AND PEEP OF 5 with an fio2 of 40% after 4 hours SBT.\n Response:\n Pt seems comfortable with the PS & satting at high 90\ns. Of note pt is\n a long time smoker of 1 ppd and is a heavy drinker 91.5 pints /day)\n with a history of withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation once patient is\n able to follow the commands & improved secretion .\n Pneumonia, other\n Assessment:\n LS rhoncherous. Afebrile, moderate amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc : 17.4.. Lactate : 1.0\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Altered mental status.\n Assessment:\n Patient opens her eyes to painful stimuli / spontaneously at times but\n does not track to follow any commands. Restless & agitated mostly ,\n trying to climb up the side rails at times.\n Action:\n Fentanyl off , midaz at 2.5 mg/hr. Halodol on PRN basis . Halodol 5\n mg IV X1 given.\n Response:\n Halodol IV with good effects.\n Plan:\n Will cont monitoring her mental status closely. Halodol for\n agitation.\n" }, { "category": "Physician ", "chartdate": "2125-10-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543302, "text": "Chief Complaint:\n 24 Hour Events:\n Vanco, levo, ctx continued, bactrim discontinued\n CT chest: Diffuse ground glass opacities, worst in the upper lobes with\n possible crazy paving appearance. Dependent nodular opacities at the\n bases. Differential is broad and includes infectious and inflammatory\n etiologies such as pneumocystis pneumonia, pulmonary alveolar\n proteinosis, and noncardiac edema. Other less likely etiologies\n include bacterial pneumonia, chronic eosinophilic pneumonia,\n hypersensitivity pneumonitis and pulmonary hemorrhage. Extensive\n pancreatic calcifications.\n Family reported concern for ethanol withdrawal - ct showing chronic\n pancreatitis.\n NGT placement.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:41 AM\n Vancomycin - 08:07 PM\n Levofloxacin - 10:40 PM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:41 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 81 (81 - 107) bpm\n BP: 92/66(242) {92/63(81) - 134/80(294)} mmHg\n RR: 17 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n FINGERSTICK GLUCOSE: 194-280 (since start of RISS)\n CVP: 21 (8 - 36)mmHg\n Total In:\n 4,096 mL\n 562 mL\n PO:\n TF:\n 509 mL\n 236 mL\n IVF:\n 3,397 mL\n 276 mL\n Blood products:\n Total out:\n 1,930 mL\n 505 mL\n Urine:\n 1,910 mL\n 505 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n 2,166 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,121 (577 - 1,121) mL\n PS : 5 cmH2O\n RR (Set): 30\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.36/44/85./23/0\n Ve: 7.8 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General:\n HEENT:\n Chest:\n Heart:\n Extrem:\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 436 K/uL\n 8.9 g/dL\n 194 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 21 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.7 %\n 25.3 K/uL\n [image002.jpg]\n 12:08 PM\n 07:00 PM\n 04:35 AM\n 04:41 AM\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n WBC\n 16.6\n 20.6\n 25.3\n Hct\n 26.6\n 26.8\n 26.7\n Plt\n 379\n 406\n 436\n Cr\n 0.8\n 0.7\n 0.6\n TCO2\n 22\n 20\n 19\n 21\n 23\n 24\n 26\n Glucose\n \n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:14/25, Alk Phos / T Bili:84/0.1, Amylase\n / Lipase:/9, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:795 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n MICRO: viral culture : pending; rapid pending.\n PCP negative 2\n Sputum culture prelim neg\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumonia. Initiated treatment for pneumonia 2 days PTA with\n azithromycin but did not improve. widespread pulmonary infiltrates,\n leukocytosis, mildly elevated temps, significant O2 requirement and\n vent support. Now clinically improving with requirement for less vent\n and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest AEP. PCP and legionella negative.\n - Continue steroids (initially on for PCP treatment with bactrim, will\n continue for presumptive diagnosis of AEP.\n - follow BAL cultures.\n - check chest CT today; still with abnormal exam\n - rapid viral insufficient; will resend with ETT aspirate.\n - For now will continue coverage for severe CAP coverage (levoflox +\n cephalosporin and vancomycin). D/c bactrim, as BAL fluid negative.\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2.\n - Try decrease PEEP to 10 this AM, can go down to 8 if PaO2 tolerates.\n - versed/fent with daily wake up\n - CXR daily\n - VAP precautions.\n - Hope for extubation as early as tomorrow given improvement.\n # Lactic acidosis. >3 this AM, no priors. HD stable, no hypotension\n or e/o hypoperfusion. Now resolved.\n # Renal function. Creatinine within normal limits but significant bump\n yesterday, now improved. Stopped bactrim.\n .\n # Depression. continue home prozac dose\n # Concern for EtOH abuse. Per family. Chronic pancreatitis per\n ICU care\n NUtren pulmonary\n Insulin sliding scale\n H2 blocker\n PPI\n CVL and Aline\n Full code\n Dispo: ICU\n" }, { "category": "Nursing", "chartdate": "2125-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543648, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression\n" }, { "category": "Nursing", "chartdate": "2125-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543649, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep5, PS 5, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with small to moderate amount white thick\n sputum. CT scan performed showed diffuse opacities throughout\n the lungs with chronic pancreatitis . No back flow from A-line & A\n line D/C\nd .\n Action:\n Fent weaned off completely and midaz @ 2.5 mg/hr . Back to vent\n with PS OF 5 AND PEEP OF 5 with an fio2 of 40% after 4 hours SBT.\n Response:\n Pt seems comfortable with the PS & satting at high 90\ns. Of note pt is\n a long time smoker of 1 ppd and is a heavy drinker 91.5 pints /day)\n with a history of withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation once patient is\n able to follow the commands & improved secretion .\n Pneumonia, other\n Assessment:\n LS rhoncherous. Afebrile, moderate amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc : 17.4.. Lactate : 1.0\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Altered mental status.\n Assessment:\n Patient opens her eyes to painful stimuli / spontaneously at times but\n does not track to follow any commands. Restless & agitated mostly ,\n trying to climb up the side rails at times.\n Action:\n Fentanyl off , midaz at 2.5 mg/hr. Halodol on PRN basis . Halodol 5\n mg IV X1 given.\n Response:\n Halodol IV with good effects.\n Plan:\n Will cont monitoring her mental status closely. Halodol for\n agitation.\n" }, { "category": "Respiratory ", "chartdate": "2125-10-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 543381, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\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: 4 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: White / Thin\n Sputum source/amount: Suctioned / Moderate\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 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: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: probable extubation in the AM... awaiting definative\n resolution of pnuemonia\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 Comments:\n" }, { "category": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 543489, "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 > did well on PS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/81(100)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 156 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 152 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,784 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 910 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 6.5 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : diffusely, Rhonchorous\n but less then yesterday: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic:, Responds to: Verbal stimuli, not following commande\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 484 K/uL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Rapid Respiratory Viral Antigen Test (Final ):\n Respiratory viral antigens not detected.\n SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND\n RSV.\n CXR : poor quality film, ? increasing effusion.\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rpaid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: Her presentation is concerning for an\n infectious source. we do not know her HIV status (although her CD4\n count is 900). Notably, her plateau pressures are not consistent with\n ARDS, there is no evidence of bleeding which would go for DAH, the cell\n count now has a neutrophil predominance, but initially she had 12%\n eosinophilia which has subsequently decreased to 1% on repeat. BAL has\n been neg on gram stain and clx as have been blood clx, a viral process\n is possible (the Ag was cancelled) and urine legionella was neg. This\n may be consistent with acute eosinophilic PNA process, there does not\n appear to be an infectious component (BAL neg and PCP neg, viral\n studies neg) and her WBC conts to rise in the setting of broad spectrum\n coverage. The Chest CT from shows a dramatic GGO and\n consolidation pattern in the upper lobes predominantly which could be\n consistent with AEP,PAP and possibly some volume overload (increased\n BNP on admission), over the last 24 hrs her WHC has improved and she\n has been Afebrile on high dose steroids (125 mg solumedrol q 6h since\n ). Hopefuil\n - Will stop Vancomycin today, cont ceftriax/levaquin.\n - Cont PS ventilation: SBT today.\n - increase methylpred to 125 mg IV q 6h and will decrease on\n \n - Let her set I/O\n - Check IgE (add on to admit): pending.\n >ETOH withdrawl / altered: on midazolam, may need CIWA and haldol in\n the extubation setting as her mental status is likely to be worsened in\n the setting of high dose steroids.\n - Will trial Haldol prior to extubation. Obtain ECG to check Qt\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2125-10-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 543502, "text": "Chief Complaint: pneumonia\n 24 Hour Events:\n - Weaned to and tolerated well. Trying to wean sedation for plan\n for extubation today.\n - Rapid viral screen negative.\n - Radiology recommends renal ultrasound for complex cyst seen\n incidentally.\n - Lasix 20 IV x 2; even at midnight but -1.7 L by 5 am.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 06:02 AM\n Ceftriaxone - 08:00 AM\n Vancomycin - 08:05 PM\n Levofloxacin - 10:05 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 11:15 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 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.1\nC (98.8\n HR: 75 (75 - 104) bpm\n BP: 129/78(100) {81/58(73) - 138/96(103)} mmHg\n RR: 11 (7 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 10 (4 - 23)mmHg\n Total In:\n 2,294 mL\n 144 mL\n PO:\n TF:\n 793 mL\n 4 mL\n IVF:\n 1,371 mL\n 140 mL\n Blood products:\n Total out:\n 2,050 mL\n 1,940 mL\n Urine:\n 2,050 mL\n 1,940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 244 mL\n -1,796 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 796 (53 - 1,050) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.44/48/99./32/6\n Ve: 7.4 L/min\n PaO2 / FiO2: 250\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)\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 but improved: )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed. Not following commands this morning.\n Labs / Radiology\n 484 K/uL\n 9.3 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 102 mEq/L\n 141 mEq/L\n 28.6 %\n 17.4 K/uL\n [image002.jpg]\n 09:01 AM\n 01:23 PM\n 05:34 PM\n 05:40 PM\n 05:50 AM\n 06:02 AM\n 03:03 PM\n 08:13 PM\n 04:44 AM\n 04:54 AM\n WBC\n 20.6\n 25.3\n 17.4\n Hct\n 26.8\n 26.7\n 28.6\n Plt\n \n Cr\n 0.7\n 0.6\n 0.7\n 0.7\n TCO2\n 21\n 23\n 24\n 26\n 28\n 34\n Glucose\n 11\n Other labs: PT / PTT / INR:15.5/23.9/1.4, CK / CKMB /\n Troponin-T:85//0.04, ALT / AST:20/25, Alk Phos / T Bili:83/0.2, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:3.0 g/dL, LDH:622 IU/L,\n Ca++:8.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 F with history of asthma (no controller meds) admit to MICU with\n respiratory distress and failure requiring intubation with severe\n pneumonia on CXR and high O2 requirements on vent; now improving\n significantly.\n # Acute pneumoniaNow clinically improving with requirement for less\n vent and oxygenation support and dramatic improvement in chest Xray.\n Consistent with noninfectious cause, also high eosinophil presence on\n BAL fluid suggest ?AEP. No peripheral eosinophilia. Does have upper\n lobe predominance on CT.\n - Continue solumedrol 125 Q6 hours today.\n - checking IgE (can be suggestive of AEP), ANCA (? vasculitis)\n - follow final BAL cultures.\n - continue coverage with levoflox + cephalosporin; d/c vancomycin.\n .\n # Respiratory failure. Requiring intubation for pneumonia/pneumonitis\n as above. Initially requiring 80-100% FiO2 and PEEP ; now\n significantly improved and comfortable of with 0.40 fiO2. Diuresed\n overnight. Weaning sedation to hopefully allow extubation today.\n - Extubate today if can wean off sedation and secretions manageable.\n SBT. Give haldol 5 mg x 1 to decrease agitation, may need some\n continued benzos given high EtOH use.\n - Negative 1.8 liters overnight\n should not need further diuresis.\n .\n # Depression. continue home prozac dose\n # Concern for EtOH abuse. Per family. Chronic pancreatitis per\n imaging. Last drink thought to be or .\n - Monitor for withdrawal once extubated and off versed. Benzos prn.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: NPO for extubation; insulin gtt off and starting scale\n Glycemic Control: Regular insulin sliding scale (can change back to\n gtt if needed since will be on high dose steroids).\n Lines:\n 18 Gauge - 04:03 AM\n Multi Lumen - 02:00 PM\n Arterial Line - 06:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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": "2125-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543996, "text": "41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 this am- able to state name only. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Cont on lactulose for possible liver disease. Ammonia level checked. MD\n called daughter this PM to question re: baseline MS.\n Response:\n MS declining throughout shift. Around 1500, pt no longer stating name,\n not following commands. Answers yes/no question to pain. Ammonia level\n WNL @ 31. Large amt loose stool post lactulose. Per pt\ns daughter, pt\n has baseline neuro defecits s/p coma yrs ago with anoxic brain\n injury. Pt does, however, live alone and perform self ADLs, and her\n speech/language is WNL at baseline.\n Plan:\n Cont to monitor MS with frequent neuro checks.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% most of shift on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Around 1500, noted to drop sats to 80s\n with good pleth.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. ABG drawn. Nasal\n trumpet placed and pt suctioned for minimal amts white/frothy\n sputem.\n Response:\n O2 sat increased to 93-96% post O2 increase and suctioning. ABG results\n 7.49/48/77. O2 decreased back to previous settings per fellow to avoid\n hypercapnea.\n Plan:\n Aspiration precautions., frequent oral suctioning, T/C/DB encouragement\n and encouragement to clear secretions. Close monitoring sats, airway.\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543036, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543038, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543379, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past\n has been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****Started on Solumedrol 125 mg IV Q6\n hrly..\n ***** Lasix 20 mg IV given X1, good response.\n **** Goal is neg 500 cc out.\n ***** Weaning off fentanyl first & midaz as tolerated .\n ***** Insulin drip started . Hourly Blood sugar.\n ***** Vent parameter changed . Weaning off vent if tolerated\n ***** Tube feeding being held since 1700 hrs for\n possible\n Extubation.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep 10, PS 8, Sats 93-96%. Ls\n rhoncherous throughout. Strong cough with small to moderate amount\n white thick sputum. CXR showed diffuse b/l opacities but improved\n over previous day .CT scan performed showed diffuse opacities\n throughout the lungs with chronic pancreatitis . No back flow from\n A-line, ABG pending.\n Action:\n sedation weaned off to 50mcgs of fent and 5 mg of versed. PT remains\n on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n .Pt seems comfortable with the PS. Of note pt is a long time smoker of\n 1 ppd and is a heavy drinker 91.5 pints /day) with a history of\n withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation if tolerated.. F/u on am\n CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous, improved after lasix 20 mg IV. Tmax 99 , moderate\n amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc remain elevated.. Lactate : 0.6.,\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Hyperglycemia\n Assessment:\n FSBS >200 mg/dl.\n Action:\n Insulin gtt started @ 3 unit/hr & titrated as per blood sugar.\n Response:\n Last FSBS 120\n Plan:\n Will cont hourly FSBS.\n" }, { "category": "Nursing", "chartdate": "2125-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542888, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression. Mother is . MD will need to speak\n with mother for consent and further history if known.\n ROS:\n Neuro: Well sedated on 100mcg of fentanyl and 5mg versed. Arousable to\n voice but attempting to sit up in bed, strong cough, worrisome that she\n could dislodge ETT. Inconsistently following commands. PERL and\n sluggish. Bolus sedation needed to properly sedate patient. B/l wrist\n restraints in place.\n Cardiac: HR 80-90 sr with no ectopy. SBP 90-100 via art line. Hct 27\n down from 32 but received 5L IVF.\n Resp: On a/c 400X26 100% +8peep. RR 26-30 with sats 94-100%. Abg\n 7.36/37/142/22. Ls rhoncherous with bibasilar crackles. Sxted for scant\n sputum. Following ARDS net ventilation.\n Gi/Gu: Abd soft and distended with hypoactive bs, no stool. Uop\n 20-30cc/hr amber and clear.\n Pneumonia, other\n Assessment:\n As above.\n Action:\n Covering with levoflox and ceftriaxone for CAP coverage. Will keep on\n vanco until BAL/cx\ns return.\n Response:\n Afebrile. WBC unchanged @15.\n Plan:\n Continue abx as ordered. F/u on BAL and bronch cx\ns. ?start\n bactrim/steroids if suspect PCP.\n Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n As above.\n Action:\n Vent settings as above.\n Response:\n Abg 7.36/37/142/22.\n Plan:\n Wean vent as tolerated, daily CXR.\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544186, "text": "Chief Complaint: Resp failure\n asthma and ? AEP\n HPI:\n Patient seen and examined with ICU residents. Plan discussed.\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 07:45 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 84 (59 - 114) bpm\n BP: 148/81(97) {126/67(84) - 177/100(118)} mmHg\n RR: 25 (13 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 149 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 89 mL\n Blood products:\n Total out:\n 2,135 mL\n 600 mL\n Urine:\n 2,115 mL\n 600 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -452 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 100%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance:\n Eyes / Conjunctiva:\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: Coarse b/l breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No c/c/e\n Skin: Not assessed\n Neurologic: Attentive, Delayed response to verbal stimuli. Follows\n simple commands. Oriented to place and year.\n Labs / Radiology\n 11.3 g/dL\n 594 K/uL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n MICRO: BCx, UCx pending. Rapid viral cx neg. Sp Cx\n bad qual.\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Continue steroid taper: goal to get down to 60 of prednisone\n -Bactrim for PCP \n 5 days for atypical PNA (?) - finished today\n -Supplemental O2 as needed\n -OOB/chair\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n -f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved dramatically since yesterday.\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition: PO\ns (soft diet) to start today\n Glycemic control: RISS\n Lines: umen - 02:00 PM\n D/C today\n NGT\n out today\n Prophylaxis: , DVT: SQH, Stress ulcer: PPI\n Code status: Full code\n Disposition : ICU, total time spent: 32 min,\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544188, "text": "41yo F with history of asthma, EtOH abuse, and psych history (cutting),\n admitted to MICU with severe pneumonia and respiratory failure\n requiring intubation with high O2 requirements on vent. Extubated \n and found to have high O2 requirements and altered MS. Pt now satting\n >93% on 3L NC, MS improving significantly with pt A&Ox3, engaging in\n conversation, tolerating POs. Probable call out .\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543097, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PCV with RR set @30, fio2 @80%, Peep +12. Overbreathing\n 34-40. Tv\ns 200-600cc\ns. Sats 95-99%. Abg 7.38/33/190. Ls rhoncherous\n with diminished bases. Strong cough with small amount white thick\n sputum. CXR from the afternoon of showed diffuse b/l opacities\n but improved over previous day.\n Action:\n Decreased fio2 to 60%, then to 40% while monitoring o2 saturation.\n Response:\n Morning abg 7.37/32/87. On Triadyne bed, tolerating turning side to\n side without any desaturation.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 99.4. Small amount of white thick sputum. NGTD on\n blood cx\ns, Bal washings and cx\ns, PCP or urine legionella.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back and Bactrim and steroids for\n prophylaxis PCP .\n Response:\n Remains with low grade temps. Wbc up slightly to 16.6. Lactate 3.7 this\n morning.\n Plan:\n Abx as ordered, f/u on cultures.\n * Received on 100mcg of fentanyl and 6mg versed. Arousable to voice and\n stimulation. As shift progressed patient waking up on own, attempting\n to sit up and and elevate arms towards ETT. 2pt soft wrist restraints\n in place. Needed to bolus sedation to keep patient safe. Does not\n follow commands. PERL. MAE.\n * HR 89-107 NSR with no ectopy. BP 108-122/60-67. Hct stable @26.6.\n * Urine output improved 30-90cc/hr. CVP 8-13 with SVV . +8.5L\n LOS.\n * Serum blood sugar >300 this morning, will need to start on SSRI. Tube\n feeds tolerated well with minimal residuals.\n * Full code. No contact from family.\n" }, { "category": "Nursing", "chartdate": "2125-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543099, "text": "P/w right sided pectoral/lung pain 2 days ago. In the past has been to\n with atypical PNA. CXR done, given abx and sent home. Represented\n this evening with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on PCV with RR set @30, fio2 @80%, Peep +12. Overbreathing\n 34-40. Tv\ns 200-600cc\ns. Sats 95-99%. Abg 7.38/33/190. Ls rhoncherous\n with diminished bases. Strong cough with small amount white thick\n sputum. CXR from the afternoon of showed diffuse b/l opacities\n but improved over previous day.\n Action:\n Decreased fio2 to 60%, then to 40% while monitoring o2 saturation.\n Response:\n Morning abg 7.37/32/87. On Triadyne bed, tolerating turning side to\n side without any desaturation.\n Plan:\n Wean vent as tolerated, monitor abg\ns. F/u on am CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous. Tmax 99.4. Small amount of white thick sputum. NGTD on\n blood cx\ns, Bal washings and cx\ns, PCP or urine legionella.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, Bactrim for prophylaxis PCP\n coverage and steroids.\n Response:\n Remains with low grade temps. Wbc up slightly to 16.6. Lactate 3.7 this\n morning.\n Plan:\n Abx as ordered, f/u on cultures.\n * Received on 100mcg of fentanyl and 6mg versed. Arousable to voice and\n stimulation. As shift progressed patient waking up on own, attempting\n to sit up and and elevate arms towards ETT. 2pt soft wrist restraints\n in place. Needed to bolus sedation to keep patient safe. Does not\n follow commands. PERL. MAE.\n * HR 89-107 NSR with no ectopy. BP 108-122/60-67. Hct stable @26.6.\n * Urine output improved 30-90cc/hr. CVP 8-13 with SVV . +8.5L\n LOS.\n * Serum blood sugar >300 this morning, will need to start on SSRI. Tube\n feeds tolerated well with minimal residuals.\n * Full code. No contact from family.\n" }, { "category": "Nursing", "chartdate": "2125-10-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543369, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past\n has been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****Started on Solumedrol 125 mg IV Q6\n hrly..\n ***** Lasix 20 mg IV given X1, good response.\n **** Goal is neg 500 cc out.\n ***** Weaning off fentanyl first & midaz as tolerated .\n ***** Insulin drip started .\n ***** Vent parameter changed . Weaning off vent if tolerated\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep 10, PS 8, Sats 93-96%. Ls\n rhoncherous throughout. Strong cough with small to moderate amount\n white thick sputum. CXR showed diffuse b/l opacities but improved\n over previous day .CT scan performed showed diffuse opacities\n throughout the lungs with chronic pancreatitis . No back flow from\n A-line, ABG pending.\n Action:\n sedation weaned off to 50mcgs of fent and 5 mg of versed. PT remains\n on PS OF 5 AND PEEP OF 5 with an fio2 of 40%.\n Response:\n .Pt seems comfortable with the PS. Of note pt is a long time smoker of\n 1 ppd and is a heavy drinker 91.5 pints /day) with a history of\n withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation if tolerated.. F/u on am\n CXR.\n Pneumonia, other\n Assessment:\n LS rhoncherous, improved after lasix 20 mg IV. Tmax 99 , moderate\n amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc remain elevated.. Lactate : 0.6.,\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Hyperglycemia\n Assessment:\n FSBS >200 mg/dl.\n Action:\n Insulin gtt started @ 3 unit/hr & titrated as per blood sugar.\n Response:\n Last FSBS 120\n Plan:\n Will cont hourly FSBS.\n" }, { "category": "Nursing", "chartdate": "2125-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543557, "text": "Patient with right sided pectoral/lung pain 2 days ago. In the past has\n been to with atypical PNA. CXR done, given abx and sent home.\n Represented 11/10with SOB with sat of 65% on room air and RR in the\n 30-40's. LS w/scattered rhonchi, placed on 100% NRB. Anxious with\n increasing WOB. Was intubated with etomidate and succs. Difficult to\n sedate, briefly paralyzed. Eventually settled on fentanyl and versed\n gtts. Abg 7.19/57/162. 98% on 100% Fio2. Bronched and BAL washings\n sent. Received cefepime, levoflox, and vanco. Blood cx's sent.\n Leukocytosis. Has received ~5L IVF but only ~70cc of urine.\n Known h/o asthma and depression.\n Significant Events on : ****SBT for aprox 4 hours. Tolerated\n well.\n **** Back to vent on CPAP/40%/ PEEP :5, PS :5\n *** Suctioned for White frothy thin secretion frequently.\n **** Held extubation for increased secretion & mental status.\n **** Possible extubation .\n **** Weaning off fentanyl .\n ***** Midaz @ low dose (2.5 mg/hr)\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP, fio2 40%, Peep5, PS 5, Sats 93-96%. Ls rhoncherous\n throughout. Strong cough with small to moderate amount white thick\n sputum. CT scan performed showed diffuse opacities throughout\n the lungs with chronic pancreatitis . No back flow from A-line & A\n line D/C\nd .\n Action:\n Fent weaned off completely and midaz @ 2.5 mg/hr . Back to vent with\n PS OF 5 AND PEEP OF 5 with an fio2 of 40% after 4 hours SBT.\n Response:\n Pt seems comfortable with the PS & satting at high 90\ns. Of note pt is\n a long time smoker of 1 ppd and is a heavy drinker 91.5 pints /day)\n with a history of withdraws per the daughter.\n :\n Wean vent as tolerated, & probable extubation once patient is\n able to follow the commands & improved secretion .\n Pneumonia, other\n Assessment:\n LS rhoncherous. Afebrile, moderate amounts of white thick secretion.\n Action:\n Ordered for MDI\ns. Continues on levo and ceftriaxone for CAP coverage,\n vanco until BAL results come back, and steroids. PM lytes sent. Started\n on Solumedrol 125 mg Q 6 hrly for high WBC count.\n Response:\n T max 99, . Wbc : 17.4.. Lactate : 1.0\n Plan:\n Abx as ordered, f/u on cultures. See flowsheet for PM lytes & lactic\n acid , Ig E.\n Altered mental status.\n Assessment:\n Patient opens her eyes to painful stimuli / spontaneously at times but\n does not track to follow any commands. Restless & agitated at times ,\n trying to climb up the side rails at times.\n Action:\n Fentanyl off , midaz at 2.5 mg/hr. Halodol on PRN basis . Halodol 5\n mg IV X1 given.\n Response:\n Halodol with good effects.\n Plan:\n Will cont monitoring her mental status closely. Halodol for\n agitation.\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544328, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly. She is\n currently A&Ox3, engaging in conversation, satting >93% on 2L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist but is slightly unsteady on feet.\n CODE: FULL\n ACCESS: #20 gauge Right forearm\n ROS:\n -neuro: A&Ox3, denies pain, cooperative with care, appropriate use of\n call light\n -CV: HR with sinus brady/sinus rhythm 50s-70s, SBP ranging 120-140s\n -resp: satting >93% on 2L, drops to 89-92% on RA, strong/productive\n cough present, LS ronchorous throughout\n -GI/GU: voiding/moving bowels on commode; stands/pivots with 1 assist;\n positive menses\n -social: lives alone in and performs self ADLs at baseline; has\n 1 daughter who lives in , MA that is involved in care\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544407, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly. She is\n currently A&Ox3, engaging in conversation, satting >93% on 2L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist but is slightly unsteady on feet.\n CODE: FULL\n ACCESS: #20 gauge Right forearm\n ROS:\n -neuro: A&Ox3, denies pain, cooperative with care, appropriate use of\n call light\n -CV: HR with sinus brady/sinus rhythm 50s-70s, SBP ranging 120-140s\n -resp: satting >93% on 2L, drops to 89-92% on RA, strong/productive\n cough present, LS ronchorous throughout\n -GI/GU: voiding/moving bowels on commode; stands/pivots with 1 assist;\n positive menses; LBM \n -social: lives alone in and performs self ADLs at baseline; has\n 1 daughter who lives in , MA that is involved in care\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544455, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly. She is\n currently A&Ox3, engaging in conversation, satting >93% RA but placed\n on 2L overnight while sleeping for o2sat 88%. Pt is tolerating POs,\n and is able to commode and chair w/ supervision (weakness persists).\n No changes in pt condition overnight. Remains called out and awaiting\n floor bed.\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544173, "text": "41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Frequent reorientation.\n Response:\n Pt with MS greatly improving throughout day and pt A&Ox3 this pm. Pt\n able to engage in conversation, tolerating POs and able to feed self\n with little help.\n Plan:\n Cont to monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% this AM on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to 3L\n NC and no high flow O2 by mid morning and pt satting 93-98%.\n Plan:\n Aspiration precautions, T/C/DB encouragement and encouragement to clear\n secretions. Close monitoring sats, airway. Encouragement incentive\n spirometer. OOB activity with nurse assist.\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544049, "text": "Altered mental status (not Delirium)\n Assessment:\n Last evening pt very somulent, oriented x1. Pt able to track and follow\n commands.\n Action:\n Pt started on lactulose for ? liver disease, ammonia levels had been\n wnl.\n Response:\n MS has been improving since yesterday. Over the course of the night pt\n more alert and can participate in minimal conversation. Pt able to talk\n about her daughter and granddaughter. Pt cont to follow commands, but\n is still only oriented to self. She did admit that she is not at home\n but can not say that she is in the hospital. Pt attempted to climb OOB\n once to get water. Bed alarm on and activated, pt reoriented.\n Plan:\n Cont lactulose, monitor MS, ? speech and swallow eval.\n Pneumonia, other\n Assessment:\n Pt did have acute episode of desaturation to 85% with good pleth. Pt\n was resting comfortably during this time.\n Action:\n FIO2 increased to 95% HI FLOW, pt NTS for small amount of white frothy\n sputum. Chest PT given.\n Response:\n Sats came back up to >95% and O2 then weaned back down to 60% HI FLOW\n and 3.0L NC. Pt given albuterol neb.\n Plan:\n Cont to wean O2 as tolerated, prn nebs, cough and deep breathe, chest\n PT, OOB to chair.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt spiked temp to 101.1 ax.\n Action:\n Pt given 650mg Tylenol and pan cultured.\n Response:\n Temp trending down.\n Plan:\n Monitor fever curve, F/U with pending culture data.\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544148, "text": "Chief Complaint: Resp failure\n asthma and ? AEP\n HPI:\n Patient seen and examined with ICU residents. Plan discussed.\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 07:45 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 84 (59 - 114) bpm\n BP: 148/81(97) {126/67(84) - 177/100(118)} mmHg\n RR: 25 (13 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 149 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 89 mL\n Blood products:\n Total out:\n 2,135 mL\n 600 mL\n Urine:\n 2,115 mL\n 600 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -452 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 100%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance:\n Eyes / Conjunctiva:\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: Coarse b/l breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No c/c/e\n Skin: Not assessed\n Neurologic: Attentive, Delayed response to verbal stimuli. Follows\n simple commands. Oriented to place and year.\n Labs / Radiology\n 11.3 g/dL\n 594 K/uL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n MICRO: BCx, UCx pending. Rapid viral cx neg. Sp Cx\n bad qual.\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: s/p extubation, tolerated well. Her\n presentation is concerning for acute eosinophilic PNA, +/- infectious\n source . BAL has been neg on gram stain and clx as have been blood clx,\n a viral process is possible (the Ag was cancelled) and urine legionella\n was neg..\n -Continue steroid taper: goal to get down to 60 of prednisone (or\n equivalent) w/n one week\n -Bactrim for PCP \n 5 days for atypical PNA (?) - finish today\n -Supplemental O2 as needed\n -OOB/chair\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n -f/u Cx\n -No additional abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved dramatically since yesterday.\n -Will continue to monitor\n -PT\n issues per ICU resident note.\n ICU Care\n Nutrition: PO\ns (soft diet) to start today\n Glycemic control: RISS\n Lines:\n Multi Lumen - 02:00 PM\n D/C today\n NGT\n out today\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544155, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n - Desat to 80s yesterday afternoon while more somnolent compared to the\n morning, ABG 7.49/48/77. Improved with suctioning and stimulation.\n - Ammonia 30.\n - Hct stable at 32 in the afternoon.\n - Prophylactic bactrim started.\n - No further diuresis.\n - Spiked to 101.1, cultured.\n Much more awake/alert today. Complains only of generalized weakness.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 PM\n Heparin Sodium (Prophylaxis) - 12:31 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 63 (59 - 114) bpm\n BP: 146/77(93) {126/67(84) - 177/100(118)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 133 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 73 mL\n Blood products:\n Total out:\n 2,135 mL\n 530 mL\n Urine:\n 2,115 mL\n 530 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 99%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\n Physical Examination\n Sitting up OOB in chair, NAD. NGT in place. Alert, oriented to and , not otherwise to date. Speech somewhat slowed but\n significantly more fluent and appropriate than yesterday.\n NC/AT. MM slightly dry.\n Lungs diffusely rhoncherous but good air entry.\n Heart regular, no murmur appreciated\n Abdomen: soft NT/ND.\n Minimal edema.\n Labs / Radiology\n 594 K/uL\n 11.3 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n # Acute pneumonia and respiratory failure.\n clinically improving,\n though still requiring O2 with intermittent desaturations. Picture C/w\n noninfectious cause, +eos in BAL and elevated serum IgE suggest AEP.\n ANCA and infection workup negative.\n - decrease solumedrol 60 Q8hrs for today.\n - started bactrim given anticipated prolonged steroid course.\n - d/c levofloxacin today\n - goal even today (has been significantly negative with metabolic\n alkalosis; will let be even or autodiurese more on own today).\n - IS and pulmonary toilet as tolerated.\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Current picture consistent with global\n delerium (med effect, infections, steroids etc). Improving overnight\n and today.\n - f/u RPR\n - continue to monitor exam\n - hold benzos, though monitor for withdrawal.\n # Fever. To yesterday. No e/o infiltrate on CXR. UA with few\n WBCs, will follow culture. Could also be atelectasis given positioning\n and lethargy at times. Also consider other infectious sources (biliary\n disease, c.diff) or other sources of fever (pancreatitis, VTE).\n - follow urine and blood cultures. Hold off on further abx\n for now.\n # Coffee ground emesis. One episode 2 nights ago after dry heaving;\n likely vs. past OGT trauma. Seems to have been self\n limited with subsequent stable Hct.\n - Change back to H2 blocker\n - If no further episodes and hct stable, would hold off on GI\n consult/scope\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: Starting with nectar/softs, advance as tolerated, consider\n formal speech and swallow in AM\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n will d/c and place peripherals.\n Prophylaxis:\n DVT: HSQ\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU for today, hope to go to floor tomorrow.\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544306, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n MULTI LUMEN - STOP 04:00 PM\n - Steroids tapered to 60 q 8 hours\n - Levaquin stopped (was on high dose for > 5 days)\n - diet advanced\n - Lactulose d/c'd as mental status had significantly improved\n - Improved mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:46 AM\n Heparin Sodium (Prophylaxis) - 07:46 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 08:02 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: 36.7\nC (98\n HR: 63 (51 - 92) bpm\n BP: 127/70(84) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 480 mL\n PO:\n 1,320 mL\n 480 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 566 K/uL\n 11.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ASTHMA\n .H/O DEPRESSION\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Comments: Regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544307, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n MULTI LUMEN - STOP 04:00 PM\n - Steroids tapered to 60 q 8 hours\n - Levaquin stopped (was on high dose for > 5 days)\n - diet advanced\n - Lactulose d/c'd as mental status had significantly improved\n - Improved mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:46 AM\n Heparin Sodium (Prophylaxis) - 07:46 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 08:02 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: 36.7\nC (98\n HR: 63 (51 - 92) bpm\n BP: 127/70(84) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 480 mL\n PO:\n 1,320 mL\n 480 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 566 K/uL\n 11.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n # Acute pneumonia and respiratory failure.\n clinically improving,\n though still requiring O2 with intermittent desaturations. Picture C/w\n noninfectious cause, +eos in BAL and elevated serum IgE suggest AEP.\n ANCA and infection workup negative.\n - decrease solumedrol 60 Q8hrs for today.\n - started bactrim given anticipated prolonged steroid course.\n - d/c levofloxacin today\n - goal even today (has been significantly negative with metabolic\n alkalosis; will let be even or autodiurese more on own today).\n - IS and pulmonary toilet as tolerated.\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Current picture consistent with global\n delerium (med effect, infections, steroids etc). Improving overnight\n and today.\n - f/u RPR\n - continue to monitor exam\n - hold benzos, though monitor for withdrawal.\n # Fever. To yesterday. No e/o infiltrate on CXR. UA with few\n WBCs, will follow culture. Could also be atelectasis given positioning\n and lethargy at times. Also consider other infectious sources (biliary\n disease, c.diff) or other sources of fever (pancreatitis, VTE).\n - follow urine and blood cultures. Hold off on further abx\n for now.\n # Coffee ground emesis. One episode 2 nights ago after dry heaving;\n likely vs. past OGT trauma. Seems to have been self\n limited with subsequent stable Hct.\n - Change back to H2 blocker\n - If no further episodes and hct stable, would hold off on GI\n consult/scope\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: Regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 544297, "text": "Chief Complaint:\n HPI:\n 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 Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544298, "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 MULTI LUMEN - STOP 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Famotidine (Pepcid) - 07:23 PM\n Heparin Sodium (Prophylaxis) - 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 07:44 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: 36.7\nC (98\n HR: 55 (51 - 92) bpm\n BP: 141/71(89) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 240 mL\n PO:\n 1,320 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Crackles : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 11.4 g/dL\n 566 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Continue steroid taper: goal to get down to 60 of prednisone\n -Bactrim for PCP \n 5 days for atypical PNA (?) - finished today\n -Supplemental O2 as needed\n -OOB/chair\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n -f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved dramatically since yesterday.\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\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": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544287, "text": "Pneumonia, other\n Assessment:\n Pt received on 3.0L NC with sats mid to high 90s most of the night. Pt\n then acutely dropped sats to 79% while sitting comfortably and\n mentating well.\n Action:\n O2 increased to 4.0L NC and HOB elevated.\n Response:\n Sats came back up to mid 90s.\n Plan:\n Cont to monitor and wean O2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544526, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:33 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds:\n Crackles : scattered )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 12.7 g/dL\n 559 K/uL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down to the point of room air.\n -Change to prednisone 60 mg PO daily.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor ( \n Pulmonary Consult\n Fellow)\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n She has been afebrile since .\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved to the point where she is at her\n baseline\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544528, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n Decreased steroids\n Went for walk, tolerating PO feeds, mental status improved\n Drank 2 large donut coffees\n Called out to floor - no bed available\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:47 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese. Off O2\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: (Breath Sounds: Now clear, no\n wheeze/rhonchi/crackles\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 559 K/uL\n 12.7 g/dL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Picture consistent with acute eosinophilic pneumonia.\n # Acute eosinophilic pneumonia and respiratory failure.. +eos in BAL\n and elevated serum IgE suggest AEP. ANCA and infection workup\n negative. s/p 7 day course of levofloxacin in addition, though\n suspicion for CAP low. Now off O2.\n - change to PO prednisone 60 starting today.\n - started bactrim given anticipated prolonged steroid course.\n - Pulmonary consult to continue on floor after callout.\n - Smoking cessation\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Delerium post extubation but now doing\n well and appears at baseline.\n - hold benzos.\n # Fever. To 101 on . No e/o infiltrate on CXR. Urines and\n bloods negative. Could be atelectasis given positioning and lethargy\n at that time. Afebrile since.\n - Followup fever curve.\n # Leukocytosis. Will add on diff today. No further fevers, may\n simply be steroid effect.\n # Coffee ground emesis. One episode on after dry heaving; likely\n vs. past OGT trauma. Seems to have been self limited with\n subsequent stable Hct.\n # depression - cont home prozac dose\n # ethanol abuse - per family, also chronic pancreatitis per imaging.\n Last drink thought to be or .\n - SW consult on floor.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 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:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544138, "text": "41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox1 this am- able to state name only. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Cont on lactulose for possible liver disease. Ammonia level checked. MD\n called daughter this PM to question re: baseline MS.\n Response:\n MS declining throughout shift. Around 1500, pt no longer stating name,\n not following commands. Answers yes/no question to pain. Ammonia level\n WNL @ 31. Large amt loose stool post lactulose. Per pt\ns daughter, pt\n has baseline neuro defecits s/p coma yrs ago with anoxic brain\n injury. Pt does, however, live alone and perform self ADLs, and her\n speech/language is WNL at baseline.\n Plan:\n Cont to monitor MS with frequent neuro checks.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% most of shift on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Around 1500, noted to drop sats to 80s\n with good pleth.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. ABG drawn. Nasal\n trumpet placed and pt suctioned for minimal amts white/frothy\n sputem.\n Response:\n O2 sat increased to 93-96% post O2 increase and suctioning. ABG results\n 7.49/48/77. O2 decreased back to previous settings per fellow to avoid\n hypercapnea.\n Plan:\n Aspiration precautions., frequent oral suctioning, T/C/DB encouragement\n and encouragement to clear secretions. Close monitoring sats, airway.\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544494, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n Decreased steroids\n Went for walk, tolerating PO feeds, mental status improved\n Drank 2 large donut coffees\n Called out to floor - no bed available\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:47 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 559 K/uL\n 12.7 g/dL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 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:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544495, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n Decreased steroids\n Went for walk, tolerating PO feeds, mental status improved\n Drank 2 large donut coffees\n Called out to floor - no bed available\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:47 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 559 K/uL\n 12.7 g/dL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Picture consistent with acute eosinophilic pneumonia.\n # Acute eosinophilic pneumonia and respiratory failure.\n clinically\n improving, though still requiring O2 now at 2L. +eos in BAL and\n elevated serum IgE suggest AEP. ANCA and infection workup negative.\n s/p 7 day course of levofloxacin in addition, though suspicion for CAP\n low.\n - decrease solumedrol 60 Q12hrs for today, then to PO prednisone 60\n starting tomorrow AM.\n - started bactrim given anticipated prolonged steroid course.\n - goal even today\n - IS and pulmonary toilet as tolerated.\n - wean O2 as tolerated.\n - Pulmonary consult to continue on floor after callout.\n - Smoking cessation\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Delerium post extubation but now doing\n well and appears at baseline.\n - hold benzos.\n # Fever. To 101 on . No e/o infiltrate on CXR. Urines and\n bloods negative. Could be atelectasis given positioning and lethargy\n at that time. Afebrile since.\n - Followup fever curve.\n # Coffee ground emesis. One episode on after dry heaving; likely\n vs. past OGT trauma. Seems to have been self limited with\n subsequent stable Hct.\n # depression - cont home prozac dose\n # ethanol abuse - per family, also chronic pancreatitis per imaging.\n Last drink thought to be or .\n - SW consult on floor.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 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:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544506, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n Decreased steroids\n Went for walk, tolerating PO feeds, mental status improved\n Drank 2 large donut coffees\n Called out to floor - no bed available\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:47 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 559 K/uL\n 12.7 g/dL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Picture consistent with acute eosinophilic pneumonia.\n # Acute eosinophilic pneumonia and respiratory failure.. +eos in BAL\n and elevated serum IgE suggest AEP. ANCA and infection workup\n negative. s/p 7 day course of levofloxacin in addition, though\n suspicion for CAP low.\n - change to PO prednisone 60 starting today.\n - started bactrim given anticipated prolonged steroid course.\n - Pulmonary consult to continue on floor after callout.\n - Smoking cessation\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Delerium post extubation but now doing\n well and appears at baseline.\n - hold benzos.\n # Fever. To 101 on . No e/o infiltrate on CXR. Urines and\n bloods negative. Could be atelectasis given positioning and lethargy\n at that time. Afebrile since.\n - Followup fever curve.\n # Coffee ground emesis. One episode on after dry heaving; likely\n vs. past OGT trauma. Seems to have been self limited with\n subsequent stable Hct.\n # depression - cont home prozac dose\n # ethanol abuse - per family, also chronic pancreatitis per imaging.\n Last drink thought to be or .\n - SW consult on floor.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 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:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544518, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly. She is\n currently A&Ox3, engaging in conversation, satting >93% on 2L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist but is slightly unsteady on feet.\n CODE: FULL\n ACCESS: #20 gauge Right forearm\n ROS:\n -neuro: A&Ox3, denies pain, cooperative with care, appropriate use of\n call light\n -CV: HR with sinus brady/sinus rhythm 50s-70s, SBP ranging 120-140s\n -resp: satting >93% on RA, strong/productive cough present, LS clear\n throughout\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 82 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, Smoker\n CV-PMH:\n Additional history: Depression\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:73\n Temperature:\n 99.2\n Arterial BP:\n S:98\n D:76\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 60 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 95% %\n 24h total in:\n 24h total out:\n 300 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:43 AM\n Potassium:\n 4.7 mEq/L\n 05:43 AM\n Chloride:\n 100 mEq/L\n 05:43 AM\n CO2:\n 26 mEq/L\n 05:43 AM\n BUN:\n 20 mg/dL\n 05:43 AM\n Creatinine:\n 0.7 mg/dL\n 05:43 AM\n Glucose:\n 179 mg/dL\n 05:43 AM\n Hematocrit:\n 37.5 %\n 05:43 AM\n Finger Stick Glucose:\n 207\n 11:00 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 -GI/GU: voiding/moving bowels on commode; stands/pivots with 1 assist;\n positive menses; LBM \n -social: lives alone in and performs self ADLs at baseline; has\n 1 daughter who lives in , MA that is involved in care\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544139, "text": "41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Cont on lactulose for possible liver disease.\n Response:\n Large amt loose stool post lactulose. Per pt\ns daughter, pt has\n baseline neuro defecits s/p coma yrs ago with anoxic brain\n injury. Pt does, however, live alone and perform self ADLs, and her\n speech/language is WNL at baseline.\n Plan:\n Cont to monitor MS with frequent neuro checks.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% most of shift on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to\n previous settings.\n Plan:\n Aspiration precautions., frequent oral suctioning, T/C/DB encouragement\n and encouragement to clear secretions. Close monitoring sats, airway.\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544215, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly, A&Ox3,\n and engaging in conversation. She is satting >93% on 3L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Frequent reorientation.\n Response:\n Pt with MS greatly improving throughout day and pt A&Ox3 this pm. Pt\n able to engage in conversation, tolerating POs and able to feed self\n with little help.\n Plan:\n Cont to monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% this AM on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to 3L\n NC and no high flow O2 by mid morning and pt satting 93-98%.\n Plan:\n Aspiration precautions, T/C/DB encouragement and encouragement to clear\n secretions. Close monitoring sats, airway. Encouragement incentive\n spirometer. OOB activity with nurse assist.\n ------ Protected Section ------\n Foley DCd @ 1430, DTV -2230. Has a commode at bedside, did attempt\n x 1 with no success. Does well standing and pivoting with assist.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:14 ------\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544525, "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 Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:30 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 07:33 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: 36.7\nC (98\n HR: 63 (50 - 77) bpm\n BP: 126/93(102) {111/51(78) - 157/97(107)} mmHg\n RR: 16 (12 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,420 mL\n PO:\n 1,420 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 300 mL\n Urine:\n 700 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 720 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds:\n Crackles : scattered )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 12.7 g/dL\n 559 K/uL\n 179 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 20 mg/dL\n 100 mEq/L\n 136 mEq/L\n 37.5 %\n 19.5 K/uL\n [image002.jpg]\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n 05:43 AM\n WBC\n 15.8\n 16.5\n 17.5\n 19.5\n Hct\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n 37.5\n Plt\n 59\n Cr\n 0.6\n 0.7\n 0.7\n 0.6\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 163\n 168\n 145\n 160\n 179\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down to the point of room air.\n -Change to Solumedrol 60 mg IV q12hr with change to PO prednisone\n tomorrow.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor ( \n Pulmonary Consult\n Fellow)\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n She has been afebrile since .\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved to the point where she is at her\n baseline\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544116, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n - Desat to 80s yesterday afternoon while more somnolent compared to the\n morning, ABG 7.49/48/77. Improved with suctioning and stimulation.\n - Ammonia 30.\n - Hct stable at 32 in the afternoon.\n - Prophylactic bactrim started.\n - No further diuresis.\n - Spiked to 101.1, cultured.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 PM\n Heparin Sodium (Prophylaxis) - 12:31 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 63 (59 - 114) bpm\n BP: 146/77(93) {126/67(84) - 177/100(118)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 133 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 73 mL\n Blood products:\n Total out:\n 2,135 mL\n 530 mL\n Urine:\n 2,115 mL\n 530 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 99%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\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 594 K/uL\n 11.3 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O ASTHMA\n .H/O DEPRESSION\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Comments: NPO, TFs with NGT currently\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544118, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n - Desat to 80s yesterday afternoon while more somnolent compared to the\n morning, ABG 7.49/48/77. Improved with suctioning and stimulation.\n - Ammonia 30.\n - Hct stable at 32 in the afternoon.\n - Prophylactic bactrim started.\n - No further diuresis.\n - Spiked to 101.1, cultured.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 PM\n Heparin Sodium (Prophylaxis) - 12:31 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 63 (59 - 114) bpm\n BP: 146/77(93) {126/67(84) - 177/100(118)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 133 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 73 mL\n Blood products:\n Total out:\n 2,135 mL\n 530 mL\n Urine:\n 2,115 mL\n 530 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 99%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\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 594 K/uL\n 11.3 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n # Acute pneumonia and respiratory failure.\n clinically improving, now\n extubated successfully. Picture C/w noninfectious cause, +eos in BAL\n and elevated serum IgE, ?AEP. ANCA and infection workup negative.\n - continue solumedrol 60 Q6hrs for one more day (changed )\n tomorrow can decrease to 60 Q8 or 12.\n - start bactrim given anticipated prolonged steroid course.\n - cont levoflox to complete tentative 10d course .\n - goal even today (has been significantly negative with metabolic\n alkalosis; will let be even or autodiurese some on own today).\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy duie to alcohol, though not yet\n at baseline (lives/functions at home alone). Given this history,\n picture consistent with global deleriumt (med effect, infections,\n steroids etc). CT without contrast negative for bleed. B12, folate,\n TSH negative. More concerning was lack of withdrawal to pain on exam\n yesterday/today, though this likely due to baseline peripheral\n neuropathy per daughter.\n - f/u RPR\n - check ammonia\n - continue to monitor exam\n - hold benzos, though monitor for withdrawal.\n - consider further imaging or neuro consult if not improving.\n # Coffee ground emesis. One episode overnight after dry heaving;\n likely vs. past OGT trauma vs. more worrisome causes\n (gastritis, esophagitis, PUD). Seems to be self limited with\n subsequent stable Hct.\n - recheck hct this afternoon.\n - ppi\n - Recheck coags; getting vitamin K for mildly increased INR\n - If no further episodes and hct stable, would hold off on GI\n consult/scope\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: NPO, TFs with NGT currently\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544125, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 07:45 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 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 84 (59 - 114) bpm\n BP: 148/81(97) {126/67(84) - 177/100(118)} mmHg\n RR: 25 (13 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 149 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 89 mL\n Blood products:\n Total out:\n 2,135 mL\n 600 mL\n Urine:\n 2,115 mL\n 600 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -452 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 100%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance: Overweight / Obese, anasarcic\n Eyes / Conjunctiva: PERRL, scleral icterus\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: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\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 11.3 g/dL\n 594 K/uL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure: s/p extubation, tolerated well. Her\n presentation is concerning for acute eosinophilic PNA, +/- infectious\n source . BAL has been neg on gram stain and clx as have been blood clx,\n a viral process is possible (the Ag was cancelled) and urine legionella\n was neg..\n -Continue steroid taper: goal to get down to 60 of prednisone (or\n equivalent) w/n one week\n -Bactrim for PCP \n x 10 days for atypical PNA (?)\n -Supplemental O2\n -OOB/chair\n >ETOH withdrawl / altered mental: CT head negative. Neuro exam is\n improving slowly. -Will continue to monitor\n -No evidence of EtOH w/d at this time. Will monitor -Continue lactulse\n for ? hepatic encephalopathy\n > Coffee-ground emesis: resolved-Continue PPI\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2125-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544126, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n BLOOD CULTURED - At 09:19 PM\n URINE CULTURE - At 09:19 PM\n SPUTUM CULTURE - At 09:46 PM\n FEVER - 101.1\nF - 09:17 PM\n - Desat to 80s yesterday afternoon while more somnolent compared to the\n morning, ABG 7.49/48/77. Improved with suctioning and stimulation.\n - Ammonia 30.\n - Hct stable at 32 in the afternoon.\n - Prophylactic bactrim started.\n - No further diuresis.\n - Spiked to 101.1, cultured.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:47 PM\n Heparin Sodium (Prophylaxis) - 12:31 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 63 (59 - 114) bpm\n BP: 146/77(93) {126/67(84) - 177/100(118)} mmHg\n RR: 18 (13 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 15 (9 - 15)mmHg\n Total In:\n 611 mL\n 133 mL\n PO:\n TF:\n 21 mL\n IVF:\n 360 mL\n 73 mL\n Blood products:\n Total out:\n 2,135 mL\n 530 mL\n Urine:\n 2,115 mL\n 530 mL\n NG:\n 20 mL\n Stool:\n Drains:\n Balance:\n -1,525 mL\n -397 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 99%\n ABG: 7.49/48/77/32/11\n PaO2 / FiO2: 128\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 594 K/uL\n 11.3 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.1 mEq/L\n 28 mg/dL\n 99 mEq/L\n 140 mEq/L\n 32.9 %\n 16.5 K/uL\n [image002.jpg]\n 06:00 PM\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n WBC\n 15.7\n 15.8\n 16.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n Plt\n \n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n TCO2\n 40\n 40\n 38\n Glucose\n 187\n 183\n 163\n 168\n 145\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n # Acute pneumonia and respiratory failure.\n clinically improving, now\n extubated successfully. Picture C/w noninfectious cause, +eos in BAL\n and elevated serum IgE, ?AEP. ANCA and infection workup negative.\n - decrease solumedrol 60 Q8hrs for today.\n - started bactrim given anticipated prolonged steroid course.\n - cont levoflox to complete tentative 10d course .\n - goal even today (has been significantly negative with metabolic\n alkalosis; will let be even or autodiurese more on own today).\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Current picture consistent with global\n delerium (med effect, infections, steroids etc). Improving overnight\n and today.\n - f/u RPR\n - continue to monitor exam\n - hold benzos, though monitor for withdrawal.\n - consider further imaging or neuro consult if not improving.\n # Coffee ground emesis. One episode 2 nights ago after dry heaving;\n likely vs. past OGT trauma. Seems to have been self\n limited with subsequent stable Hct.\n - ppi for now\n - If no further episodes and hct stable, would hold off on GI\n consult/scope\n # depression - cont home prozac dose\n # ethanol abuse - per family, chronic pancreatitis per imaging. Last\n drink thought to be or .\n - Monitor for withdrawal.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: NPO, TFs with NGT currently\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544205, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly, A&Ox3,\n and engaging in conversation. She is satting >93% on 3L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist.\n Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Frequent reorientation.\n Response:\n Pt with MS greatly improving throughout day and pt A&Ox3 this pm. Pt\n able to engage in conversation, tolerating POs and able to feed self\n with little help.\n Plan:\n Cont to monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% this AM on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to 3L\n NC and no high flow O2 by mid morning and pt satting 93-98%.\n Plan:\n Aspiration precautions, T/C/DB encouragement and encouragement to clear\n secretions. Close monitoring sats, airway. Encouragement incentive\n spirometer. OOB activity with nurse assist.\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544203, "text": "Altered mental status (not Delirium)\n Assessment:\n A&Ox2 this am- able to state name and year. Able to follow commands\n consistently and answer yes/no questions. Tracking with eyes.\n Action:\n Frequent reorientation.\n Response:\n Pt with MS greatly improving throughout day and pt A&Ox3 this pm. Pt\n able to engage in conversation, tolerating POs and able to feed self\n with little help.\n Plan:\n Cont to monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt satting 93-100% this AM on 3L NC and 36% high flow O2. Weak,\n nonproductive cough present. Noted to drop sats to 80s with good pleth\n this AM while being given neb treatment.\n Action:\n NC turned up to 5L, high flow O2 turned up to 95%. Pt encouraged to\n C/DB, using incentive spirometer.\n Response:\n O2 sat increased to 93-99% post O2 increase. Able to decrease O2 to 3L\n NC and no high flow O2 by mid morning and pt satting 93-98%.\n Plan:\n Aspiration precautions, T/C/DB encouragement and encouragement to clear\n secretions. Close monitoring sats, airway. Encouragement incentive\n spirometer. OOB activity with nurse assist.\n" }, { "category": "Nursing", "chartdate": "2125-10-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544191, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly, A&Ox3,\n and engaging in conversation. She is satting >93% on 3L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist.\n" }, { "category": "Nutrition", "chartdate": "2125-10-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 544364, "text": "Objective\n Pertinent medications: HISS, Pepcid, Solumedrol, MVI\n Labs:\n Value\n Date\n Glucose\n 160 mg/dL\n 03:12 AM\n Glucose Finger Stick\n 329\n 12:00 PM\n BUN\n 24 mg/dL\n 03:12 AM\n Creatinine\n 0.6 mg/dL\n 03:12 AM\n Sodium\n 134 mEq/L\n 03:12 AM\n Potassium\n 4.4 mEq/L\n 03:12 AM\n Chloride\n 99 mEq/L\n 03:12 AM\n TCO2\n 29 mEq/L\n 03:12 AM\n PO2 (arterial)\n 77 mm Hg\n 03:10 PM\n PCO2 (arterial)\n 48 mm Hg\n 03:10 PM\n pH (arterial)\n 7.49 units\n 03:10 PM\n pH (urine)\n 8.0 units\n 09:43 PM\n CO2 (Calc) arterial\n 38 mEq/L\n 03:10 PM\n Albumin\n 3.2 g/dL\n 03:52 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:12 AM\n Phosphorus\n 4.0 mg/dL\n 03:12 AM\n Ionized Calcium\n 1.15 mmol/L\n 04:21 PM\n Magnesium\n 2.1 mg/dL\n 03:12 AM\n ALT\n 18 IU/L\n 03:00 AM\n Alkaline Phosphate\n 72 IU/L\n 03:00 AM\n AST\n 17 IU/L\n 03:00 AM\n Total Bilirubin\n 0.5 mg/dL\n 03:00 AM\n WBC\n 17.5 K/uL\n 03:12 AM\n Hgb\n 11.4 g/dL\n 03:12 AM\n Hematocrit\n 33.2 %\n 03:12 AM\n Current diet order / nutrition support: DIET: soft, thin liquids\n GI: soft/obese, (+) bs (+) flatus; (+) sm bm\n Assessment of Nutritional Status\n Specifics:\n Pt w/ PNA. Extubated . TF off since in anticipation of\n extubation. Pt lethargic w/ 1 episode of coffee ground emesis after\n extubation. NGT placed and Lactulose given. Pt started on nectar\n thick liquids and soft solids. MS now improved. Pt tolerating po\n w/o swallowing difficulty. Noted elevated BS.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: encourage po\n BS mgmt\n rec tighten HISS\n Will follow up to check po\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544329, "text": "41yo F with PMH significant for asthma, EtOH abuse, neuro deficits of\n unclear origin, and psych issues (cutting). Pt was recently treated\n in the ED for c/o right sided CP/SOB/cough and was found to\n have atypical PNA. She was discharged on azithromycin, but returned to\n the ED after calling EMS with no improvement in symptoms and\n being found with O2 sat of 65% on RA. Pt was initially satting 95% on\n NRB in ED, but became tachypneic to 40s-50s and required intubation.\n She was admitted to MICU with severe pneumonia and respiratory failure\n with high O2 requirements on vent. She was extubated and found to\n have altered MS. On pt with MS improving significantly. She is\n currently A&Ox3, engaging in conversation, satting >93% on 2L NC, is\n tolerating POs, and is able to stand and pivot to commode/chair with\n assist but is slightly unsteady on feet.\n CODE: FULL\n ACCESS: #20 gauge Right forearm\n ROS:\n -neuro: A&Ox3, denies pain, cooperative with care, appropriate use of\n call light\n -CV: HR with sinus brady/sinus rhythm 50s-70s, SBP ranging 120-140s\n -resp: satting >93% on 2L, drops to 89-92% on RA, strong/productive\n cough present, LS ronchorous throughout\n -GI/GU: voiding/moving bowels on commode; stands/pivots with 1 assist;\n positive menses; LBM \n -social: lives alone in and performs self ADLs at baseline; has\n 1 daughter who lives in , MA that is involved in care\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544335, "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 MULTI LUMEN - STOP 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Famotidine (Pepcid) - 07:23 PM\n Heparin Sodium (Prophylaxis) - 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 07:44 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: 36.7\nC (98\n HR: 55 (51 - 92) bpm\n BP: 141/71(89) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 240 mL\n PO:\n 1,320 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Crackles : scattered but much\n improved.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal. A+O x 3\n Labs / Radiology\n 11.4 g/dL\n 566 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n CXR : improved aeration, resolving left lower lobe atelectasis\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Change to Solumedrol 60 mg IV q12hr with change to PO prednisone\n tomorrow.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n Could be consistent\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved dramatically since yesterday.\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 544339, "text": "Chief Complaint: hypoxic respiratory failure\n 24 Hour Events:\n MULTI LUMEN - STOP 04:00 PM\n - Steroids tapered to 60 q 8 hours\n - Levaquin stopped (was on high dose for > 5 days)\n - diet advanced\n - Lactulose d/c'd as mental status had significantly improved\n - Improved mental status, back at baseline.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:46 AM\n Heparin Sodium (Prophylaxis) - 07:46 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 08:02 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: 36.7\nC (98\n HR: 63 (51 - 92) bpm\n BP: 127/70(84) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 480 mL\n PO:\n 1,320 mL\n 480 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\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: (Breath Sounds: Rhonchorous, though much less so.\n Good air entry.\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent edema\n Skin: Not assessed\n Neurologic: Attentive, Follows all commands, Movement: Not assessed,\n Tone: Not assessed. Speech fluent and appropriate.\n Labs / Radiology\n 566 K/uL\n 11.4 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 41 F with history of asthma, EtOH abuse, psych history; admit to MICU\n with respiratory failure requiring intubation with severe pneumonia on\n CXR and high O2 requirements on vent; now improving significantly.\n Picture consistent with acute eosinophilic pneumonia.\n # Acute eosinophilic pneumonia and respiratory failure.\n clinically\n improving, though still requiring O2 now at 2L. +eos in BAL and\n elevated serum IgE suggest AEP. ANCA and infection workup negative.\n s/p 7 day course of levofloxacin in addition, though suspicion for CAP\n low.\n - decrease solumedrol 60 Q12hrs for today, then to PO prednisone 60\n starting tomorrow AM.\n - started bactrim given anticipated prolonged steroid course.\n - goal even today\n - IS and pulmonary toilet as tolerated.\n - wean O2 as tolerated.\n - Pulmonary consult to continue on floor after callout.\n - Smoking cessation\n # mental status changes\n per daughter, has history of anoxic brain\n injury as well as peripheral neuropathy due to alcohol.\n Lives/functions at home alone. Delerium post extubation but now doing\n well and appears at baseline.\n - hold benzos.\n # Fever. To 101 on . No e/o infiltrate on CXR. Urines and\n bloods negative. Could be atelectasis given positioning and lethargy\n at that time. Afebrile since.\n - Followup fever curve.\n # Coffee ground emesis. One episode on after dry heaving; likely\n vs. past OGT trauma. Seems to have been self limited with\n subsequent stable Hct.\n # depression - cont home prozac dose\n # ethanol abuse - per family, also chronic pancreatitis per imaging.\n Last drink thought to be or .\n - SW consult on floor.\n # Renal cyst. Will need followup renal ultrasound to evaluate.\n ICU Care\n Nutrition:\n Comments: Regular, swallowing well\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: change to PPI given long term plans for steroids.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544344, "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 MULTI LUMEN - STOP 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Famotidine (Pepcid) - 07:23 PM\n Heparin Sodium (Prophylaxis) - 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 07:44 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: 36.7\nC (98\n HR: 55 (51 - 92) bpm\n BP: 141/71(89) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 240 mL\n PO:\n 1,320 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Crackles : scattered but much\n improved.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal. A+O x 3\n Labs / Radiology\n 11.4 g/dL\n 566 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n CXR : improved aeration, resolving left lower lobe atelectasis\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Change to Solumedrol 60 mg IV q12hr with change to PO prednisone\n tomorrow.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor ( \n Pulmonary Consult\n Fellow)\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n She has been afebrile since .\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved to the point where she is at her\n baseline\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 544359, "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 MULTI LUMEN - STOP 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:15 AM\n Levofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Famotidine (Pepcid) - 07:23 PM\n Heparin Sodium (Prophylaxis) - 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 07:44 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: 36.7\nC (98\n HR: 55 (51 - 92) bpm\n BP: 141/71(89) {114/59(73) - 156/84(101)} mmHg\n RR: 17 (12 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,670 mL\n 240 mL\n PO:\n 1,320 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n Blood products:\n Total out:\n 1,445 mL\n 300 mL\n Urine:\n 1,045 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 225 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Crackles : scattered but much\n improved.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal. A+O x 3\n Labs / Radiology\n 11.4 g/dL\n 566 K/uL\n 160 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 99 mEq/L\n 134 mEq/L\n 33.2 %\n 17.5 K/uL\n [image002.jpg]\n 03:52 AM\n 11:50 AM\n 03:17 PM\n 04:21 PM\n 12:16 AM\n 04:16 AM\n 01:53 PM\n 03:10 PM\n 03:00 AM\n 03:12 AM\n WBC\n 15.7\n 15.8\n 16.5\n 17.5\n Hct\n 31.3\n 32.2\n 31.1\n 32.2\n 32.9\n 33.2\n Plt\n 66\n Cr\n 0.6\n 0.6\n 0.7\n 0.7\n 0.6\n TCO2\n 40\n 40\n 38\n Glucose\n 183\n 163\n 168\n 145\n 160\n Other labs: PT / PTT / INR:15.0/25.6/1.3, CK / CKMB /\n Troponin-T:95//0.04, ALT / AST:18/17, Alk Phos / T Bili:72/0.5, Amylase\n / Lipase:/9, Differential-Neuts:89.3 %, Lymph:6.0 %, Mono:4.6 %,\n Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.2 g/dL, LDH:456 IU/L,\n Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n CXR : improved aeration, resolving left lower lobe atelectasis\n Assessment and Plan\n 41 yo with hx of asthma (by report) who was recently treated for PNA\n with abx and returned to the ED several days later with hypoxemic\n respiratory failure which based on BAL eosinophilia and rapid\n radiographic improvement is compatible at least in part with acute\n eosinophilic PNA with possible superinfection.\n > Hypoxemic resp failure likely d/t AEP: s/p extubation, tolerated\n well. Her presentation is concerning for acute eosinophilic PNA, +/-\n infectious source . All Cx are neg to date. She improved dramatically\n with steroids. Currently, still has some O2 requirment, likely \n atelectasis, but as her mental status is continuing to improve and she\n is able to cough, take deep breaths and get OOB to chair, her O2\n requirement has been coming down.\n -Change to Solumedrol 60 mg IV q12hr with change to PO prednisone\n tomorrow.\n -Bactrim for PCP \n O2 as needed\n -OOB/chair\n - Pulm consult to follow on the floor ( \n Pulmonary Consult\n Fellow)\n - Goal even today .\n > Fever: no clear source of infection. CXR without new infiltrates. All\n Cx pending. Atelectasis, DVT (has been on ppx), etc are on the DDx.\n She has been afebrile since .\n - f/u Cx, no abx for now\n > Neuro: H/o brain injury and peripheral neuropathy. Neurologic exam\n and mental status have improved to the point where she is at her\n baseline\n -Will continue to monitor, PT\n issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:08 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Radiology", "chartdate": "2125-10-26 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1045919, "text": " 4:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess ngt placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with multifocal pna with ngt placement now s/p extubation\n REASON FOR THIS EXAMINATION:\n assess ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement status post extubation.\n\n COMPARISON: at 5:16 a.m.\n\n FINDINGS: Single AP view of the chest performed at 1619 hours is submitted.\n Tip of the right IJ line is at the junction of the SVC and right atrium. Tip\n of the NG tube is within the stomach. The lungs are clear of focal\n infiltrate.\n\n IMPRESSION: NG tube within the stomach. Status post extubation compared to\n the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-10-22 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1045052, "text": " 2:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess central line placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with central line insertion\n REASON FOR THIS EXAMINATION:\n Please assess central line placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 7:02 PM\n Right IJ catheter with tip in mid SVC. No pneumothorax. Endotracheal tube\n less than 1 cm from carina and will need to be pulled back approximately \n cm.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FOLLOWING PORTABLE LINE PLACEMENT\n\n HISTORY: 41-year-old woman with central line insertion. Please assess for\n line position.\n\n COMPARISON: Chest radiograph from , at 12:44 a.m. This\n study was performed at 2:30 p.m.\n\n FINDINGS: The right-sided IJ catheter's tip terminates in the mid SVC. There\n is no pneumothorax. The endotracheal tube's tip terminates less than 1 cm\n from the carina and will need to be pulled back approximately 3-4 cm for\n appropriate position. A nasogastric tube courses through the esophagus enters\n the stomach and passes off the field of view.\n\n There is diffuse bilateral airspace opacity which has improved compared to\n prior study and is likely representative of improving ARDS or pulmonary edema.\n There are no pleural effusions. The cardiac silhouette is normal in size and\n the hilar and mediastinal contours appear unremarkable.\n\n IMPRESSION:\n 1. Right-sided IJ catheter tip in mid SVC. No pneumothorax.\n 2. Endotracheal tube tip less than 1 cm from the carina and will need to be\n withdrawn approximately 3-4 cm for appropriate positioning.\n 3. Improved bilateral airspace disease.\n\n These findings were communicated to Dr. by telephone at 3:14 p.m.\n on .\n\n" }, { "category": "Radiology", "chartdate": "2125-10-22 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1045053, "text": ", MED MICU-7 2:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess central line placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with central line insertion\n REASON FOR THIS EXAMINATION:\n Please assess central line placement.\n ______________________________________________________________________________\n PFI REPORT\n Right IJ catheter with tip in mid SVC. No pneumothorax. Endotracheal tube\n less than 1 cm from carina and will need to be pulled back approximately \n cm.\n\n" }, { "category": "ECG", "chartdate": "2125-10-27 00:00:00.000", "description": "Report", "row_id": 245751, "text": "Sinus arrhythmia. Poor R wave progression. Compared to the previous tracing\nof arrhythmia is present.\n\n" }, { "category": "ECG", "chartdate": "2125-10-26 00:00:00.000", "description": "Report", "row_id": 245979, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2125-10-21 00:00:00.000", "description": "Report", "row_id": 245980, "text": "Moderate artifact in lead V1. Probably within normal limits. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844874, "text": " 9:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left MCA stroke. Shortness of breath. Assess ET tube placement.\n\n PORTABLE SUPINE AP CHEST, 1 VIEW: Comparison is made to .\n\n There is an ET tube 3.5 cm above the carina. There is a left subclavian line,\n unchanged in position. There is no pneumothorax. There is no significant\n change in appearance of the heart lungs, or bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844509, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change in PNA or CHF\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation\n REASON FOR THIS EXAMINATION:\n Please eval for interval change in PNA or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left MCA stroke and shortness of breath, respiratory distress.\n\n COMPARISON: Nine hours earlier.\n\n SINGLE VIEW CHEST, AP SUPINE: The NG and ET tubes are in unchanged\n and appropriate positions. The left subclavian CVL tip is in unchanged\n position in the SVC. There is a percutaneous G-J feeding tube identified over\n the abdomen. The patient is status post median sternotomy and CABG. There is\n bibasilar atelectasis and pleural effusions cannot be excluded. Pulmonary\n vasculature is within normal limits.\n\n IMPRESSION:\n 1. Appropriate placement of tubes and lines.\n 2. Bibasilar atelectasis.\n 3. No left ventricular heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844755, "text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 y/o man with left MCA stroke, shortness of breath.\n Endotracheal tube placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The endotracheal tube, left subclavian line remain in place. The\n heart is mildly enlarged in size. Again, note is made of tortuous aorta,\n unchanged compared to the previous study. The patient is status post CABG\n with median sternotomy. Again, note is made of bilateral pleural effusions\n with bibasilar patchy atelectasis, unchanged compared to the prior study.\n There is a slight uppe zone redistribution of the pulmonary vasculature,\n suggesting mild CHF vs. volume overload.\n\n IMPRESSION: Continued mild cardiomegaly and mild CHF, with bibasilar pleural\n effusions and patchy atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2180-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844972, "text": " 9:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? crepitus at TLC site.\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation.\n\n REASON FOR THIS EXAMINATION:\n ? crepitus at TLC site.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to 1 day earlier.\n\n INDICATION: Crepitus at triple lumen catheter site.\n\n A left subclavian vascular catheter remains in satisfactory position\n terminating in the proximal superior vena cava. There is no evidence of\n pneumothorax or significant subcutaneous emphysema. ETT also remains in\n satisfactory position. Cardiac and mediastinal contours are stable. Bibasilar\n atelectasis is again demonstrated, with slight improvement at the left lung\n base. There are also persistent small pleural effusions.\n\n IMPRESSION: No evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2180-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845095, "text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement.\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation.\n\n REASON FOR THIS EXAMINATION:\n ET tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left MCA stroke and SOB. Status post intubation, check\n position for endotracheal tube.\n\n CHEST:\n\n FINDINGS: The film is somewhat under penetrated and the exact position of the\n endotracheal tube is difficult to assess. A repeat film would be necessary to\n exactly determine its position but it does not appear to be significantly\n different from the prior chest x-ray. Elevation of the left hemidiaphragm is\n present and some areas of atelectasis and possible infiltrate is seen in the\n left lower lobe. The right hemidiaphragm is obscured. Left subclavian line\n has been removed.\n\n IMPRESSION: Bilateral basilar atelectasis left lower lobe infiltrate not\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2180-11-20 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 844484, "text": " 12:22 AM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: TACHYCARDIA,TACHYPNEA,HYPOXIA.R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with tachycardia, tachypnea, hypoxia\n REASON FOR THIS EXAMINATION:\n Eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ESE MON 3:00 AM\n No pulmonary embolism.\n Right lower lobe dependent opacities, possibly representing atelectasis vs.\n infection.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Tachycardia, tachypnea, hypoxia.\n\n TECHNIQUE: Chest CTA technique was used. Precontrast and contrast enhanced\n images were obtained of the chest from the lung apices through the diaphragms.\n Multiplanar reformatted images were obtained. 150 cc of Optiray contrast\n were administered.\n\n COMPARISON: Noncontrast chest CT, .\n\n CHEST CT W/O&W IV CONTRAST: The pulmonary arteriovasculature is adequately\n visualized down to the segmental branches. No filling defects are present.\n\n There are extensive coronary artery and aortic calcifications. No mediastinal\n masses are present. There is collapse and consolidation at the right lung\n base. Patchy opacities are present in the right lower lobe dependently.\n Atelectasis is present in the left lower lobe. There is no pneumothorax.\n Scattered calcified pleural plaques are present.\n\n The visualized portions of the upper abdomen are unremarkable. The osseous\n structures reveal no suspicious lytic or sclerotic lesions.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatted images confirm the above\n mentioned findings. These images demonstrate the endotracheal tube to be low\n lying, approximately 2 cm from the carina. This may be withdrawn several\n centimeters for optimal positioning.\n\n IMPRESSION:\n 1) No pulmonary embolus.\n\n 2) Collapse and consolidation at the right lung base. This is likely due to\n atelectatic changes, however, an infectious process is also possible.\n\n 3) Endotracheal tube low lying, with tip 2 cm from the carina. This may be\n withdrawn several centimeters for optimal positioning.\n (Over)\n\n 12:22 AM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: TACHYCARDIA,TACHYPNEA,HYPOXIA.R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2180-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844485, "text": " 12:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for CVL and ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p CVL placement. ETT tube\n pulled back 2 cm from prior\n REASON FOR THIS EXAMINATION:\n Eval for CVL and ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left MCA stroke and shortness of breath status post central venous\n line placement.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of one hour earlier.\n There is a new left subclavian central venous line with tip in the upper\n superior vena cava. There is no pneumothorax. Nasogastric tube is unchanged\n in position. The endotracheal tube is positioned with tip approximately\n 3 cm from the carina. The cardiomediastinal silhouette and appearance of the\n lungs are unchanged.\n\n IMPRESSION:\n New left subclavian central venous line with tip in the upper superior vena\n cava. No pneumothorax. Endotracheal tube positioned with tip 3 cm from the\n carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844482, "text": " 11:59\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for ETT, NGT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation.\n REASON FOR THIS EXAMINATION:\n Eval for ETT, NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left anterior stroke, shortness of breath, status post intubation\n and nasogastric tube placement.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of one hour earlier.\n There has been interval placement of an endotracheal tube. The tip is below\n the thoracic inlet, 2 cm from the carina. There is a nasogastric tube which\n is coiled in the stomach. The cardiomediastinal silhouette and appearance of\n the lungs is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 844480, "text": " 10:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob,\n\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left MCA stroke and shortness of breath.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of .\n The patient is status post sternotomy. The cardiomediastinal silhouette is\n stable. The lung volumes are low. There are patchy opacities at the lung\n bases. The opacity at the left lung base is slightly improved from the prior.\n The pulmonary vascularity is at the upper limits of normal, likely indicating\n a degree of vascular congestion. There may be bilateral pleural effusion.\n\n IMPRESSION:\n 1. Bibasilar opacities. These may represent atelectasis or infiltrate.\n 2. Prominent pulmonary vasculature, likely consistent with mild fluid\n overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 844483, "text": " 12:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent stroke s/p TPA with worsened mental status\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ESE MON 2:44 AM\n Evolving Left MCA stroke.\n No acute hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent stroke with worsening mental status.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without IV contrast.\n\n COMPARISON: head CT.\n\n HEAD CT: There is a large area of low attenuation in the left cerebral\n hemisphere consistent with known evolving left MCA stroke. There are no areas\n of high attenuation to suggest acute hemorrhage. Other chronic infarctions in\n the thalami, right basal ganglia, and left cerebellum are again noted. There\n is no mass effect and no shift of normally midline structures. There is stable\n appearance of a left vertebral aneurysm.\n\n The osseous structures and visualized paranasal sinuses are unremarkable.\n\n IMPRESSION:\n Subacute left MCA infarction. No acute hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845182, "text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement.\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L MCA stroke and sob, s/p intubation.\n\n REASON FOR THIS EXAMINATION:\n ET tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stroke, recently extubated.\n\n CHEST: The ETT has been removed. Bibasilar atelectasis present. Cardiomegaly\n is seen and degree of failure is probably present.\n\n A gastrojejunostomy tube is present.\n\n IMPRESSION: Patient extubated. Atelectasis and mild failure.\n\n" }, { "category": "ECG", "chartdate": "2180-11-28 00:00:00.000", "description": "Report", "row_id": 157814, "text": "Sinus rhythm\nConduction defect of RBBB type\nInferior ST-T changes are nonspecific\nSince pervious tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 157815, "text": "Sinus rhythm\nConduction defect of RBBB type\nInferior ST-T changes are nonspecific\nSince previous tracing of , ventricular arrhythmia not seen\n\n" }, { "category": "ECG", "chartdate": "2180-11-19 00:00:00.000", "description": "Report", "row_id": 157816, "text": "Sinus tachycardia\nVentricular couplets\nShort PR interval\nMarked right axis deviation\nRight bundle branch block\nSince previous tracing of , the rate has increased and ventricular\npremature complex seen\n\n" }, { "category": "Nursing/other", "chartdate": "2180-11-23 00:00:00.000", "description": "Report", "row_id": 1381651, "text": "NPN\n\nNeuro: Pt is alert, following commands, noding yes nad no to questions, moving his left (L) arm purposefuly, moving his L leg on the bed, he did move his right (R) leg reflexively, I did not move his R arm. Plan - Cont to follow his neuro exam, make note of any changes.\n\nCV: Systolic blood pressure (BP) 160-90, HR heart rate (HR) 70s-50s, dropped his HR and BP after his captopril and lopressor - they were not given simultaneously. He has been having PVCs, his K was 3.7 this morning and he was given 40 meq. The plan is to continue with the lopressor and captopril provided that his BP tolerates it, the team would like to continue to diuresis him as his BP allows.\n\nResp: Lung sounds coarse, they do sound fairly clear after suctioning. He has been having clear to white thin sputum in large (lg) amounts, also he has a lg amount of the same type of sputum from his mouth. He was on PS 8, 5 PEEP, 40% for the morning with a resp rate in the upper 20s, min 7-9 liters, this afternoon he was decreased to with the same rate and min ventinlation, he was then placed on 0/5 and again with a resp rate in the upper 90s and a min vent of liters. The plan is to leave him on over night and extubate in the morning if he conts to do well.\n\nGI: He conts with his TFs and has been tolerating them with low residuals, his rate is presently at 40cc/hr with a goal of 70cc/hr. He conts with 250cc water boluses for a sodium of 147. His stool is loose and OB neg. Plan increase the TF as tolerated.\n\nGU: U/O was low this morning 5-20cc/hr, he was given 20 mg of IV lasix with about 600cc out, he is still ~ 500cc pos since midnight (MN). The plan is for him to be 500-1000cc neg at MN and lasix will continue to be given as his BP tolerates it.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-23 00:00:00.000", "description": "Report", "row_id": 1381652, "text": "Respiratory Care note\nPt. weaned to tol well. Trialed on SBT tolerated well. Plan to remain on for night and extubate in AM if stable. Suctioned large amts of white secrections.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-24 00:00:00.000", "description": "Report", "row_id": 1381653, "text": "NPN 1900-0700\nNeuro: Pt , able to follow commands appropriately, nods yes and no answers to questions, Moves LUE and LLE in bed, RUE and RLE without mvmt, SR up x 4, pt environment secure.\n\nResp: Lungs coarse to auscultation A&P chest, on CPAP this am FIO2 40%, PEEP 5, PS 5, TV 281, RR 26-28, RISBE at 0500 97. Sx'd . amt of white thin sputum from ET tube and mouth. Given 20mg lasix overnight with minimal effect, 20mg Lasix verbally ordered per HO for am however currentl BP is 98/32 and lasix held.\n\nCV: HR 55-76 SB-SR with PVC's, one episode of 4-beat run of , pt asymptomatic, SBP's 96-143/45-55. 40mEq KCL given per NGT, please see morning labs prior to adm. lasix.\n\nGI: BS (+), continues to have loose brown stool via colostomy OB (-), stoma pink in color, abd soft non-distended, non-tender. TF advanced to 60cc/hr, turned off at 0500 for possible extubation.\n\nGU: FOley cath intact draining pink colored urine with sediment early into shift, now urine is straw colored with sediment, UO in adequate amts. UA with reflex sent.\n\nSocial: Wife in to see pt last night.\n\nPlan: Continue to monitor VS, diurese as ordered when BP allows, see am labs.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-25 00:00:00.000", "description": "Report", "row_id": 1381658, "text": "NPN\n\nNeuro: Pt is , following commands, his right (R) arm remains flacid, he moves his left (L) arm purposefully, moving his feet in the bed. He is aphasic from the CVA and did not talk after extubation but does nod yes and no to questions.\n\nCV: Pt was placed on IV nitroglycerin (NTG) just prior to extubation for afterload reduction, this was shut off due to his sytolic BP was 99. Heart rate 60s-90s - it increased to the 90s while on the NTG and then decreased to the 80s after it was shut off. He has rare to frequent PVCs, his K this afternoon was 4.1. He remains on 12.5 mg of lopressor , the captopril was d/ced yesterday. Plan cont to follow his vital signs, cont with the captopril, follow his serum potasium, he tends to have more ectopy if his K is < 4.0.\n\nResp: Pt was placed on 5 pressure support and 0 of PEEP, 40% FI02, his VTs were 200-300cc, RR 26-35, 02 SAT 100%, cough, requiring frequent suctioning - every 1 hour. He was extubated at 2 pm and has done well. 02 SAT 100% on 35 % cool neb, RR low to mid 30s, nodded yes when asked if he was breathing well. He has not had many secreations since he was extubated. Plan: Follow lung sounds, keep head of bed >30 degrees, if he does need to be reintubated than a trache needs to be further discussed with the patient and the family.\n\nGI: His tube feeding was stopped this morning, if he conts to do well extubate than they can be restarted later this evening.\n\nGU: His urine output was good this morning but has drifted down to ~ 40cc/hr, cont to follow, plan is to keep his ins and outs even.\n\nSoc: Family was in today, appropriately concerned.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-26 00:00:00.000", "description": "Report", "row_id": 1381659, "text": "NPN 1900-0700\nResp: Pt extubated yest at 1400. LS coarse with crackles in R base and diminished in L, but not worsening during shift. Rare, weak, non-productive cough. RR 24-30, encouraged deep breathing with minimal ability/willingness by pt to deeply. Attempted inhalers without good deep , RT gave nebulizers. Pt appeared comfortable breathing, nodded yes that he was comfortable. O2 sats 96-98 without o2, droping sats to 91-92. Replaced cool neb on pt, 35%. Sometimes pt pulled it off, but o2 sat still high. Off and on during noc. CO2 from am labs 34.\n\nNeuro: Pt , follows commands, aphasic, but tries to talk making sounds but not words. Pt usually calm and cooperative, but refused few treatents, ie refused to have teeth brushed while son was visiting, first refused inhaler then gave in. Pt moving LUE, moves feet in bed, no movement of RUE.\n\nCV: HR 61-78, nsr with pvcs, couplets. K this am 3.7, will start new order of 20mEq KCLx2. BP 98/57-130/62. Map <60, team aware, preferred not to give extra flds despite I&O neg 700mls yest. Tmax 97.2.\n\nGI: +BS. Colostomy bag in place with minimal loose stool. TF restarted at 2330. Currently at 50mls/hr with goal of 70mls.\n\nGU: Small urine output, 10-20mls/hr, team aware and preferred no flds given.\n\nSocial: Son visited last evening, very supportive of pt.\n\nPlan: Monitor BP, urine output and flds. Monitor HR for ectopy and follow lytes. Replete lytes. Encourage pt to C&DB. Encourage increased mouth care.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-28 00:00:00.000", "description": "Report", "row_id": 1381665, "text": "NPN\n\nNeuro: Pt , following commands, more awake today than yesterday. No change in his mobility, out of bed to cardiac chair via a lift. This afternoon he looked uncomfortable - he was grimicing, grinding his teeth and doing cousmal breathing, pt would nod yes and no to the same questions ie does your stomach , you have chest pain, are you uncomfortable. HO in to see pt, EKG done and was unchanged from previous ones, ABD is distended but it has been, he does have stool from his colostomy, changing his position seems to eleviate his discomfort.\n\nCV: SBP 100-160s, HR 60s-70s, rare to occational PVCs, his lopressor was held due to a SBP of 90, his lisinopril was d/ced and he was started on 40mg of lasix every day.\n\nResp: Lung sounds rales 1/2 up from bases bilat, RR upper 20s, he did have cousmal breathing with discomfort, 02 SATs upper 90s.\n\nGI: ABD distended, pos bowel sounds, stooling brown loose stool.\n\nGU: Pt was given 40 mg of lasix per NG tube with ~ 800cc out thus far.\n\nDiso: Pt to go to today.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 1381635, "text": "Resp Care: Pt received from ER intubated with #7 ett secured @ 22 @ lip, placed on ventilatory support with a/c, spo2 100%; bbs rhonchorous, sxn thick yell secretions, will titrate vent settings as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 1381636, "text": "npn\npt admitted from ew at 530am from rehab for sob ? chf, cxr showing bilat pleural edema.\nneuro: pt sedated in ew with ativan ivp. started on fent and versed upon admit to micu. has received bolues of both 3 mg versed and 100 mcg fent total during aline placement. pt basically unresponsive wsith bath and turning but is moving head and left arm with line placement.\ncad hr 80's sr with pvc's b/p 106 systolic.\nresp pt vented on acx14x500x80%fio2 peep5. ls coarse with wheeezing noted in bases.\ngi: jtube clamped. osotmy needs to be redone but ? needed to be seen by otomy nurse. bs+ small amt of golden liquid stool in ostomy.\ngu: urine output clear yellow . blood weeping from around penis ? trauma from foley placement.\nid: temp max in ew 100.4 ax. blood cx sent in ew and vancomycin 1 gm given.\nsocial wife , son and daughter went home, number is in ew paper work.\nplan: aline placement, wean sedation and ? weaning of vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 1381637, "text": "RESP: BS'S COARSE TO CLEAR AT NOONTIME. FIO2 DROPPED TO 40% WITH O2 SATS RUNNING AT 100%. HO TO TRY TO OBTAIN ABG'S NOW AND THEN VBG'S TO FOLLOW. NO FURTHER CHANGE ON VENT. SUCTIONED FOR SMALL AMTS OF THICK YELLOW.\nNEURO: SEDATION 'D. PT. SOMEWHAT MORE AWAKE. EYELIDS FLUTTERING. MOVING LEFT SIDE ON BED. BITING DOWN ON SUCTION CATHETER.\nGI: NUTRITION CONSULT TO START TF'INGS. PT. HAS A FUNCTIONING PEG. OGT NEEDS TO BE REMOVED. COLOSTOMY BAG WORKING WELL. SMALL AMT OF LIQUID BROWN STOOL NOTED. NEED TO CONSULT THE OSTOMY NURSE.\nRENAL: 3X FLUID BOLUSES OF 500CC GIVEN WITH SOME INCREASE IN U/O'S. IVF'S AT KVO.\nENDOC: LYTES STABLE. K+ 4.6. CK IN 200'S. NO SSI REQUIRED.\nID: BLOOD CX'S SENT X2 AS WELL AS A SPUTUM CX. CONT. ON ANTIBIOTICS. TEMP 100. AX TODAY.\nCV: PT NOTED TO HAVE PVC'S AND RUNS OF VT OF BEATS. SON STATES ADMISSION HE HAD RUNS OF VT AS WELL. CONT. ON LOPRESSOR. SERIAL CK'S TODAY.\nSOCIAL: SON AND WIFE INTO VISIT. SON STATES HIS FATHER SPEAKS VERY LITTLE ENGLISH.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 1381638, "text": "RESPIRATORY CARE: PT ADMITTED FOR ARF R/T PNA V. CHF.\nPT W/ 7.0 ORAL ETT IN PLACE. AC MODE 14/500/.40/5 PEEP.\nABG C/W A MILD RESPIRATORY ALKALOSIS AND GOOD OXYGENATION.\nSX FOR THICK YELLOW SPUTUM SENT TO LAB BY RN. C/W CURRENT\nVENTILATOR SETTINGS.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-20 00:00:00.000", "description": "Report", "row_id": 1381639, "text": " pm NPN\nRESP: pt remains intubated and vented on AC 40%/500/14 5 Peep, O2 sats 100% unable to place a-line. vbg~38/44/7.37 suctioned q 3-4 hrs for thick yellow secretions. CT angio~no PE, RLL consolidation/infiltrate.\n\nSEDATION: pt on Versed gtt @.5 mg/hr, Fentanyl @ 20 mcg/hr~ d'cd at 8pm, pt slowly waking up, with eyes opening, coughing on ETT, no movement of right side, left arm and leg small movement. left hand restrained for safety. PERL 2 mm.\n\nGI: OGT tube d'cd. pt with peg. tube feeds restarted Impact with fiber @ 30 cc/hr (goal is 70 cc/hr). +BS, belly soft\n250 cc free H20 bolus q 4 hrs. Ostomy bag changed (supplies in room)\n\nGU: foley draining clear, yellow urine UO~20-30cc/hr\n\nCV: bp stable 107/55 HR 60-70's SR with PVC. CVP 3-4 repeat cpk sent pending.\n\nID: t max 99.4 po WBC 7.6 pt on Zosyn, Levo, and Vanco blood cultures pending.\n\nENDO: FS WNL no insulin required.\n\nIV LINES: IV RN to see pt, unable to instill 1mg Alteplase. PICC line will need to be pulled by IV team in am.\n\nA: RESP Failure, Pneumonia, increased NA\n\nP: when pt more awake, change to pressure support, sx as needed, antibx, prn fluid boluses, follow cvp and uo. pt is full code. have IV team pull picc line.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-21 00:00:00.000", "description": "Report", "row_id": 1381640, "text": "Resp Care\nPt. remains intubated/sedated overnight with no changes.\nBs: coarse bilat. with crackles at bases. Sxn'd x1 for copious tan thick, otherwise secreations minimal.\nPlan: wean to pressure support during days.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-21 00:00:00.000", "description": "Report", "row_id": 1381641, "text": "FULL CODE Contact Precautions MRSA NKDA\n\n\nNeuro: Pt has not received any sedation since last evening and is comfortable. Moves L extrems spont, no movement noted un L extrems. Opens eyes to verbal stim, but doesn't follow commands. Weak cough w/ suctioning and impaired gag w/ mouth care.\n\nCV: HR=70s, NSR w/ freq PVCs, but no runs PVCs tonight. BP=100-120s/70s. Weak pulses, extrems cool. On Lopressor .\n\nResp: On AC 500x14, 40%,P-5 and will try PS mode this am to assess for extubation. Sx large amt thick tan secretions via ETT. Lungs coarse BS bilat, diminished in bases. 02sat 99-100%.\n\nGI/GU: Abd softly distended, +BS, no BM via colostomy. TF held at midnight for possible extubation. Free H20 boluses. Foley cath w/ cludy yellow urine; U/A, C/S sent last evening.\n\nAccess: Lsubcl TLC patent. R upper arm PICC, clotted. IV nurse attempted to unclot last evening w/ TPA, unsuccessful and 2nd dose attempted tonight - will check at 0630 if 2nd dose worked.\n\nPain: Does not appear to be in any discomfort.\n\nSocial: No calls or visits.\n\nID: T=99.4 axil - on Vanco, Zosyn and Levaquin.\n\nEndo: FS=109-98, required no insulin coverage per RISS.\n\nLabs: CBC/INR ok - lytes pending.\n\nPlan: Attempt to wean today if tol. Replete lytes prn. Monitor neuro/resp/cardiac status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-11-21 00:00:00.000", "description": "Report", "row_id": 1381642, "text": "RESP: BS'S COARSE SOUNDING. SUCTIONED FOR MOD-COPIOUS AMTS OF TAN SECRETIONS. LAVAGED. JUST NOW UNABLE TO SUCTIONED D/T BITING OF TUBE. ORAL AIRWAY PLACED WITH GOOD MV'S AND RR. PLACED ON PS 15/5 TODAY. O2 SATS 100%. DOES BECOME APNEIC AT TIMES.\nNEURO: AWAKE AND ALERT. NODDING APPROPRIATELY AT TIMES. OBVIOUSLY AWARE OF TUBE. REFUSED TO OPEN HIS MOUTH ON COMMAND. LIFTS LEFT HAND AND MOVES LL ON BED.\nGI: TF'INGS RESUMED AT 30CC/HR. VIA PEG. NO RESIDUALS. CONTINUES WITH 250CC FREE WATER Q4HRS. NO STOOL VIA COLOSTOMY.\nRENAL: NO U/O AT 14PM. FOLEY IRRIGATED UNSUCCESSFULLY. FOLEY REMOVED AND ATTEMPT AT REINSERTING UNSUCCESSFUL. PT. DID URINATE RIGHT AFTER FOLEY REMOVED. CONDOM CATH PLACED. NO BLOOD IN URINE, BUT DID HAVE BLOOD AT END OF FOLEY CATH. WHEN REMOVED. IF PT. DOESN'T VOID, HE NEED A COUDE OR UROLOGY RESIDENT TO SEE PT. ALSO WITH INSERTION PT. WAS GRIMACING WITH PAIN. IVF'S AT 100CC/HR.\nENDOC: NO SSI REQUIRED FOR BS'S. LYTES OK. NEEDS LYTES AT 16PM.\nHEM: HCT DROP TODAY. NO OBVIOUS SOURCE. COULD BE FROM HYDRATION. CHECK HCT AT 16PM.\nID: AFEBRILE. CONT. ON ANTIBIOTICS.\nCV: CAPTOPRIL ORDERED, BUT NOT GIVEN AT 14PM. BP JUST 100. HO IS AWARE. IF BP IMPROVES AT 16PM. WOULD GIVE. CVP 6-12.\nACCESS: PICC AND LEFT TRIPLE LUMEN.\nSOCIAL: SPOKE AT LENGTH WITH SON BY PHONE RE: HIS FATHER AND HIS WISHES TO COME HOME. HO WILL SPEAK WITH HIM WHEN HE COMES WITH RE: TO DNR STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-21 00:00:00.000", "description": "Report", "row_id": 1381643, "text": "Respiratory care note\nPt weaned to PSV tolerated well. Will continue to wean as tolerated. Pt suctioned for mod. amts of tan secrections.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-21 00:00:00.000", "description": "Report", "row_id": 1381644, "text": "addendum to the above note: fmaily mtg held to discuss medical status. pt' son understands all the facets of his care and will discuss with his sister wether pt's code status should be changed to dnr. will offer emotional support to family and keep them well informed on a daily basis. pt coonitnues to receive frr water boluses of 250cc's q 4 hrs. condom cath not intact. #16 fr 5 cc balloon foley cath placed with adequate uo. continue with present medical management.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-22 00:00:00.000", "description": "Report", "row_id": 1381645, "text": "Resp Care\nPt. remains intubated overnight, rested on AC mode. Switched back to pressure support this morning following RSBI.\nBs: rhonchi bilat. sxn'd for copious tan and . blood tinged sputum.\nNo abgs\nWould not recommend extubating pt. today d/t increased sputum production and borderline rsbi.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-22 00:00:00.000", "description": "Report", "row_id": 1381646, "text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT, NO SEDATION, MOVING LEFT SIDE EXTREMETIES. NO MOVEMENT ON RIGHT. PEARL. FOLLOWING SOME COMMANDS. CONT TO BITE ON ETT, ESPECIALY WHEN SUCTIONING. PT HAS POSITIVE GAG/COUGH REFLEX. RECEIVED VERSED 2MG X 1 LAST EVENING TO HELP SLEEP.\n\nRESP: PT RECEIVED ON CPAP/WITH PRESSURE SUPPORT 15/+5 40%. PT SUCTIONED SEVERAL TIMES FOR AMT'S OF THICK TAN SECRETIONS. PT TIRED OUT AROUND MIDNIGHT WITH RESP RATES IN THE 30'S AND WAS PLACED BACK ON A/C TO REST. ETT ROTATED TO THE LEFT SIDE OF THE MOUTH, 22 AT THE LIP. PT TOOK ORAL AIRWAY OUT BUT NEEDE TO BE REPLACED TO PREVENT FURTHER BITING OF THE TUBE. LUNG SOUNDS COARSE WITH SOME WHEEZES HEARD ON THE RIGHT. PT BACK ON CPAP THIS AM AND TUBE FEEDS HAVE BEEN HELD AT 0500 FOR POSSIBLE EXTUBATION.\n\nCV: PT IN NSR WITH /FREQ PVC'S. RECEIVED LOPRESSOR/CAPTOPRIL AND DROPPED PRESSURE TO THE 70'S. PT GIVEN 250CC FLUID BOLUS WITH FAIR RESPONSE OVER TIME. 0400 DOSE OF CAPTOPRIL HELD. HCT STABLE.\n\nGI: TUBE FEEDS VIA PEG AT 30-40/HR. ABD SOFT BUT QUITE DISTENDED. PT PASSING AMT'S OF FLATUS WITH SM AMT OF LOOSE BROWN STOOL. SMALL AMT OF PURULENT DRAINAGE AROUND PEG SITE. AREA CLEANSED AND BACITRACIN APPLIED WITH DSD. RECEIVED 20MEQ KCL VIA PEG FOR K+ OF 3.3 THIS AM.\n\nGU: FOLEY CATH DRAINING ADEQ AMT'S OF PINK TINGED URINE.\n\nFLUID: 1/2NS RUNNING AT 100/HR. ENDO: NO SSRI TONIGHT.\n\nSOCIAL: HAVE NOT HEARD FROM FAMILY MEMBERS TONIGHT. PT FULL CODE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-22 00:00:00.000", "description": "Report", "row_id": 1381647, "text": "MICU/SICU NPN HD #4\nNo events\n\nS/O:\n\nNeuro: pt is alert, able to communicate by nodding/shaking head, attempts to mouth words/speak with ETT and OPA in place, no movement of right side extremities, normal strength LUE, moving LLE on bed, denies pain\n\nResp: remians intubated on PSV 10+5/0.40, LS coarse, Suctioned q2h for large amts thick clear secretions, copious oral secretions, Sp)2 98-100%\n\nCV: AVSS, NSR with frequent PVC's, please see flowsheet for data\n\nSkin: C/W/D/I\n\nGI/GU: abd soft, NT/ND, restarted Impact with fiber this PM, goal rate is 70cc/h, Foley is patent for cloudy yellow urine in small amts, fair response to 20mg IV Lasix this PM\n\nLines: PICC in right AC, left SC TLCL\n\nID: afebrile on Zosyn and Vancomycin\n\nFEN: IVF d/c'd, K+ repleted\n\nA:\n\naltered breathing r/t incresed respiratory secretions\nhigh risk fo infection r/t invasive lines, ETT, indwelling catheter\nhigh risk for injury r/t right side hemiparesis\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue to wean resp support as toerated, contniue aggressive pulmonary toilet, continue abx as ordered, continue nutritional support as reccomneded, plan to diurese ~1L/day over the next few days to facilitate weaning\n" }, { "category": "Nursing/other", "chartdate": "2180-11-22 00:00:00.000", "description": "Report", "row_id": 1381648, "text": "Respiratory Care\nPt. remains on PSV weaned pressure . Suctioning tan secrections. If pt. becomes tired increase support.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-23 00:00:00.000", "description": "Report", "row_id": 1381649, "text": "Respiratory Care Note:\n\nPt remain orally intubated & breathing spont awake, easily arousable. We increased IPS from 10 to 12 cmh2o for o/n only (due to increse WOB)and was able to put back this morning and tol so far. BS are dim and rhonchorous. WE sxtn for large amt of white secretions. SSBI done (on 7 IPS) reveals bordeline results.\nPlan: will suggest to continue ICU settings and incresae IPS if needed. Not ready for elective extubation. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-23 00:00:00.000", "description": "Report", "row_id": 1381650, "text": "NPN 1900-0700\n\nNeuro: Alert, answering yes and no questions. Affect is flat and depressive. Slept poorly. R side flaccid, L arm moves freely, L leg moves minimally.\nCV: NBP 83-139/33-57, SBP dropped to 78 ~1hr after getting captopril and metoprolol; HO notified, BP improved shortly after on its own without intervention; HR 55-85, SR with frequent PVC's.\nResp: Remains intubated on vent with C-pap/psv 10-12/5/.4. Requiring frequent suctioning for large amounts of off white sputum. Pt has a strong cough. Lungs are coarse in upper lobes but clear with suctioning, diminished lower lobes. O2 sats 96-100%\nGI: Abdomen soft, ND, NT, +BS. Colostomy intact, drained ~150cc loose brown stool. TF increased to 30/hr; no residuals; free water boluses restarted. J-tube intact and without s/sx of infection.\nGU: Foley catheter intact draining 20-150/hr; 24hr balance +5, LOS +7 liters.\nID: Tmax 97.6; remains on zosyn.\nEndo: Blood sugar 116 at midnight, am pending.\nPlan: wean from vent ASAP; suction frequently; monitor resp and cardiac status; TF as ordered and tolerated; fsbg qid.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-11-24 00:00:00.000", "description": "Report", "row_id": 1381654, "text": "Respiratory Care Note:\n\npt reamin orally intubated on minimal spontaneous ventilation. RSBI this AM ~ 97. We are still sxtn for mod amt of thick yellow secretions. Plan: ? elective extubation, unless secretions and WOB becomes more stable.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-24 00:00:00.000", "description": "Report", "row_id": 1381655, "text": "NPN\n\nNeuro: Pt is , follows commands, he moves his L (left) arm well - over his head, down to his side, he does not move his right (R) arm, he moves both feet in the bed, L more so than his R. He seems depressed, he admits to feeling discouraged with all that he has been through. - ETT, CVA.\n\nCV: Blood pressure stable (BP) 100-160, HR 60s sinus with PVCs. potasium stable. He was given 40mg of IV lasix today with the hopes of diuresing him further to improve his chances for extubation, he has had ~ 700cc out, the plan is for his to be ~ 1500 neg by midnight.\n\nResp: LS coarse, he remains on PS 5 PEEP 5, 40%, RR mid to upper 20s, VTs 6-9 liters. The plan is to extubate tomorrow morning, the team felt that he needed to be further diuresed prior to extubation.\n\nGI: The tube feeding (TF) was restarted today since he will not be extubated, ABD soft,, conts to have loose to liquid stool from his colostomy. Plan d/c TF at midnight for probable extubation.\n\nGU: Given IV lasix 40mg, wsith ~ 700cc out so far, plan is for his to be 1500cc neg by midnight.\n\nAccess: his triple lumen was d/ced, he had little bumps around his neck, the did not crackle like cripitus, he did not have any blood return from any of the lines, he had a stat CXR and a pneumo was not seen. The line was removed, he has a PIC and we wanted to decrease his infection risk.\n\nSoc: His son and wife were in today.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-25 00:00:00.000", "description": "Report", "row_id": 1381656, "text": "Resp Care,\nPt. remains intubated on IPS 8 overnoc. VT 300, RR 30. Suctioned for white sputum. RSBI 95 this am with ATC on. Placed on SBT 5am. Possible extubation, see carevue.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-25 00:00:00.000", "description": "Report", "row_id": 1381657, "text": "S/MICU Nursing Progress Note\n Respiratory: Pt remains intubated on settings of PSV 5cm and PEEP of 5cm, suctioning minimal secretions until 4am, frequency and amount of secretions increased, tx with lasix. Bs coarse throughout.\n Neuro: , unable to move right arm, moving left arm and following commands. moving legs on the bed, left >right.\n Cardiac: Hr 58-80 NSR with occasional PVC's BP 100-130/50's finished yesterday 1100 neg. urine output decreasing and by 6am increasing frequency of suctioning, white thin secretions. 40mg IV lasix given. K 3.9 20 KCl given at 5am. less ectopy after dose given.\n GI; receiving TF at 60cc/hr TF stopped at 6 am for possible extubations. sm amt of liquid stool via colostomy.\n GU: foley in place and draining well\n Social: family in during the evening. sister of the patient.\n Endo: FS at 12 am. no insulin coverage needed. am Fs pnd\n Plan: continue to monitor I&O's closely, try to keep neg plan is to try an extubation this morning. hold TF until extubated.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-26 00:00:00.000", "description": "Report", "row_id": 1381660, "text": "NPN\n\nNeuro: Pt is , following commands, moving his left arm with full range of motion, moving his left leg in the bed, his right leg in the bed and his right arm is flacid. He is aphasic but will nod his head yes and no to questions.\n\nCardiac: SBP 100-150s, HR 60s-80s SR with occational PVCs, he has been tolerating his lopressor, he has not been given any lasix today but the plan is to keep him even so he will probably need some lasix tonight.\n\nResp: Lung sound coarse, he is coughing up thick light yellow sputum, 02 SATs mid to upper 90s though occationally drops to the low 90s, resp rate upper 20s.\n\nGI: Colostomy is draining brown stool, conts on TF at 70cc/hr which is his goal.\n\nGU: U/O 15-40cc/hr , he is 500cc pos since midnight, the plan is for him to be even - he will need lasix tonight.\n\nSoc: His family called today and came in later this evening.\n\nDispo: Pt to be transfered to tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-27 00:00:00.000", "description": "Report", "row_id": 1381661, "text": "NPN (NOC): PT HAD A GOOD NIGHT. RR TEENS TO 20'S, REGULAR, NONLABORED. SATS HAVE BEEN IN THE MID TO UPPER 90'S ON ROOM AIR. SOUNDS CLEAR EXCEPT CRACKLES IN RIGHT LOWER LOBE. STILL REFUSING TO WEAR NEBS. LASIX 40 MG IV GIVEN AT MIDNIGHT WITH 900 CC RESPONSE SO FAR. TOLERATING TUBE FEEDS WELL. OSTOMY BAG CHANGED FOR A SMALL AMOUNT OF LOOSE BROWN STOOL.\n\nPLAN: TO RETURN TO REHAB TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-27 00:00:00.000", "description": "Report", "row_id": 1381662, "text": "NPN\n\nNeuro: Pt has been more sleepy today though is easily arousible, he conts to follow commands, no change in his mobility, he was seen by PT please refer to their eval.\n\nCV: Increased ectopy today with up to an 8 beat run of VT. His K this morning was 3.9 and his Mg was 1.8, he was given 20 meq of KCl and 2 gms of Mg S04 with decreased ectopy, his repeat K was 4.2.\n\nResp: LS with rales 1/2 up from the bases, occationally coughing, afebrile today, resp rate in the upper 20s, 02 SAT in the upper 90s, he was restarted on his antibiotics today because his sputum culture came back with gram pos and gram neg organisms.\n\nGI: Conts to drain brown stool from his colostomy, remains on TF at his goal rate of 70cc/hr.\n\nGU: U/O 10-50cc/hr, no lasix has been given today.\n\nDispo: Pt to be transfered to tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-27 00:00:00.000", "description": "Report", "row_id": 1381663, "text": "Patient without wheezes,treated with 2.5mg albuterol in .5 mg atrovent*1. Admitted from hosp days ago post resp failure and evidence of pulmonary edema. Plan to go back to in AM.\n" }, { "category": "Nursing/other", "chartdate": "2180-11-28 00:00:00.000", "description": "Report", "row_id": 1381664, "text": "npn\nneuro: pt in evening. pt is aphasic and also italian speaking only, does follow some commmands, ie helping with turning. pt sleeping off and on thru out night shift\npain: fidgeting over bed in lae am pt repositioned with good effect\ncad hr 70 to 80's with rare pvc's am K+ drawn. sbp 100 to 120's no issues lopressor given.\nresp ls clear with dim bases. no lasix given overnight sats 98 - 100%\ngi: tolerating tf at 70cc/hr approx. 50cc loose stool from colostomy.\ngu: uo seemed to fall off after 12am attempt to repostion for better flow which worked. uo approx. 40cc/hr pt is over 6 liters ++ for los\nid afebrile\nsocial son and wife at bedside on eves\nplan: discharge to in am ** son spoke with day staff concerning family and pt wanting pt not to return to . issue needs to be brought to case managers attention in am. cont to monitor vs, labs, resp status\n" } ]

[ { "category": "Radiology", "chartdate": "2190-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 786572, "text": " 2:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with chest pain\n\n REASON FOR THIS EXAMINATION:\n acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n CHEST, PORTABLE AP: Comparison made to chest x-ray of . The\n heart size is within normal limits. The mediastinum is not widened. Streaky\n opacities are seen in the left retrocardiac region, consistent with\n atelectasis. There is also a small amount of atelectasis at the right lung\n base. No acute infiltrates. No pneumothorax. No evidence of congestive\n heart failure.\n\n IMPRESSION: No acute infiltrates. No evidence of congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2190-05-02 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 786584, "text": " 5:54 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ?PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p pancreas transplant and ex-lap now with tachcardia\n and chest pain\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35 year old male s/p pancreas and kidney transplant, now with\n chest pain and tachycardia.\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest were\n obtained following the administration of 100 cc of Optiray due to patient\n history of renal transplant. CTA protocol was utilized, and coronal\n reformatted images were obtained.\n\n CTA CHEST: The visualized pulmonary arterial tree does not demonstrate any\n filling defects indicative of pulmonary embolus. Several subcentimeter\n prevascular lymph nodes are present, as well as a 1.1 x .8 cm pretracheal\n lymph node. Several subcentimeter subcarinal lymph nodes are identified. The\n visualized lungs demonstrate bibasilar atelectatic changes. The lungs are\n otherwise clear and there are no pleural or pericardial effusions. The\n visualized osseous structures demonstrate no abnormalities.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolus.\n\n 2. Mediastinal adenopathy as described above.\n\n 3. Bibasilar atelectatic changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT", "row_id": 786897, "text": " 9:33 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: ? shoulder injury left side\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p pancreas transplant who fell in room and landed on\n shoulder. He has tenderness in area. r/o fracture. Has FROM.\n REASON FOR THIS EXAMINATION:\n ? shoulder injury left side\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P pancreas transplant, fell and landed on shoulder, with\n tenderness. Rule out fracture.\n\n shoulder, 3 vws\n\n There are several small calcifications about the left shoulder, the largest\n measuring approximately 1 cm. Several of these appear to represent calcific\n tendinitis related to the infraspinatus tendon. However, two others project\n adjacent to the superior edge of the greater tuberosity on the external\n rotation view and the possibility of small fracture fragments cannot be\n entirely excluded. However, they appear relatively well corticated and are\n more likely to be chronic findings. The proximal humerus itself is intact,\n without evidence of significant fracture. The glenohumeral articulation and\n AC joint are preserved. No rib fracture is identified in the upper portion of\n the chest.\n\n IMPRESSION:\n\n 1) Calcific tendinitis, unrelated to the acute traumatic event.\n 2) Tiny calcific fragments adjacent to greater tuberosity, which are also\n more likely chronic. Otherwise, no evidence of proximal humeral fracture or\n glenohumeral dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-22 00:00:00.000", "description": "PANCREAS US", "row_id": 785736, "text": " 2:09 PM\n PANCREAS US Clip # \n Reason: s/p pancreas transplant, assess arterial anastomosis, vein a\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with\n REASON FOR THIS EXAMINATION:\n s/p pancreas transplant, assess arterial anastomosis, vein and flows\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 35 y/o man status post pancreas transplant, assess arterial\n anastomosis, vein and flows.\n\n FINDINGS: A pancreatic transplant is seen in place sagittally oriented to the\n left of midline. There is abundant arterial and venous flow to the\n transplant. There is no evidence of either arterial or venous insufficiency.\n A small amount of fluid is seen surrounding the transplant and note is made of\n an in situ drain.\n\n IMPRESSION: Abundant arterial and venous flow to pancreatic transplant. No\n peri-transplant fluid collections.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-04-27 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 786152, "text": " 11:18 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ro sbo after panc tx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with\n REASON FOR THIS EXAMINATION:\n ro sbo after panc tx\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, TWO VIEWS.\n\n HISTORY: Pancreatic transplant, bowel symptoms, question SBO.\n\n FINDINGS: There are midline surgical staples and left lateral abdominal and\n bilateral pelvic surgical clips. The bowel gas pattern is normal with gas and\n stool seen throughout the colon. There is no evidence of obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-28 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 786256, "text": " 12:25 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: S/P PRANCREATIC TRANSPLANT AND KIDNEY, INCREASED ABDOMINAL PAIN/WBC\n Field of view: 36 Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p pancreas transplant with increased abdominal pain.\n increased wbc. ?collection\n REASON FOR THIS EXAMINATION:\n evaluated peri-pancreatic area (transplant)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient after pancreas transplantation with increasing abdominal\n pain.\n\n TECHNIQUE: Helical contiguous axial images were obtained from the lung bases\n to the level of the symphysis pubis. 100 cc of Optiray was injected.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n Atelecatatic changes are noticed in both lung bases. No pleural effusion is\n seen. There is normal enhancement of the liver. The intra- and extrahepatic\n bile ducts are not dilated. The spleen and both adrenals are unremarkable.\n There is atrophy of the native pancreas. There is faint enhancement of both\n native kidneys which are partially atrophied. The bowel loops are\n unremarkable. Small quantity of air fluid is noticed within the abdomen near\n the liver.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n The transplanted kidney is noticed in the right lower quadrant. There is\n normal enhancement and excretion of the contrast material. The ureter is not\n enlarged. The transplanted pancreas lies in the left lower quadrant. There is\n mild dilatation of the main pancreatic duct with a meausurement of 2.8 mm. No\n focal abnormalities are noticed within the pancreas. There is fluid around the\n pancreas and also in the pelvis. The urinary bladder is unremarkable.\n\n Bone windows are unremarkable. Surgical clips are same in the cutaneous tissue\n in the anterior abdominal wall.\n\n IMPRESSION:\n 1. Free fluid around the pancreas and within the abdomen and pelvis.\n 2. Mild dilatation of the main pancreatic duct.\n 3. Normal enhancement and excretion of the contrast material from the\n transplanted kidney.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-28 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 786268, "text": " 2:46 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: SCANNED EARLIER TODAY WITH FLUID COLLECTION IN PELVIS.? DRAINAGE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p pancreas transplant (past kidney transplant) with abd pain.\n CT today shows pelvic collection\n REASON FOR THIS EXAMINATION:\n fluid collection in pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient after pancreas transplantation with abdominal pain and\n fluid within the abdomen and pelvis.\n\n TECHNIQUE: Helical contiguous axial images were obtained from the lung bases\n to the level of the symphysis pubis. No IV contrast was administered.\n\n PROCEDURAL CT:\n Linear atelectasis are noticed in both lung bases. The liver, spleen and both\n adrenals are unremarkable. The pancreas is atrophied. Both native kidneys are\n small and atrophic with enhancement of the cortex and excretion of the\n contrast materials. A small quantity of effusion is noticed near the liver.\n The bowel loops are unremarkable.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST:\n The transplanted kidney excrete the contrast material with no hydronephrosis.\n The transplanted pancreas is found in the left lower quadrant with mild\n dilatation of the main pancreatic duct. Fluid is noticed in the pelvis. A\n Foley catheter was inserted in the urinary bladder.\n\n There is wall calcification of the iliac vessels.\n\n Informed consent from the patient. The patient was scanned in the supine\n position and in the right lateral decubitus. The fluid in the pelvis is free\n fluid and this appeared when the patient was placed in the right lateral\n decubitus and the fluid mooved out of his pelvis. There is no safe window for\n tapping the fluid and the procedure was cancelled. The patient was transferred\n to the ultrasound for further assessment.\n\n IMPRESSION:\n 1) Small quantitiy of free fluid in the abdomen and pelvis.\n 2) No safe place for aspiration of free abdominal fluid was found and the\n procedure was cancelled. The patient was sent to US for further assessment.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 785589, "text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Check status following line placement. R/O pneumothorax.\n\n FINDINGS: Single AP supine view. Comparison study of taken\n upright. A right IJ central line is noted, in good position with its tip in\n the mid SVC. The ETT and the NG tube also appear satisfactorily positioned.\n There is moderate left ventricular enlargement of the heart and there also is\n evidence of some prominence of both hilar regions and possible widening of\n superior mediastinum. These changes are partly due to the supine position of\n the patient. This should be re-evaluated with the patient upright when\n clinically feasible. No new pulmonary infiltrates or pleural effusions\n demonstrated.\n\n IMPRESSION: Widening of superior mediastinum and prominence of hila probably\n postural. An upright view is recommended when possible.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 785547, "text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op for pancreas transplant\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with\n REASON FOR THIS EXAMINATION:\n pre-op for pancreas transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative evaluation for pancreatic transplant.\n\n FINDINGS: Two AP upright images of the chest.\n\n COMPARISON STUDY: . The heart is within normal limits in size. The\n pulmonary vessels are unremarkable. The lungs are clear. No pleural\n effusions are identified. Some surgical clips are noted anterior to the right\n lung hilum. No other significant abnormality is identified.\n\n IMPRESSION: No acute cardiopulmonary abnormality. Right hilar surgical clips\n noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-04-20 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 785588, "text": " 11:22 PM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: ?INCORRECT NEEDLE COUNT\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN SINGLE VIEW:\n\n HISTORY: Incorrect instrument count.\n\n No surgical instruments detected. Surgical drain is present left mid abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2190-04-29 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 786377, "text": " 3:30 PM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: please perform duplex of transplanted pancreas to eval blood\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man s/p pancreas after kidney transplant with worsening glucose\n control and elevated amylase/lipase. ? flow to graft.\n REASON FOR THIS EXAMINATION:\n please perform duplex of transplanted pancreas to eval blood flow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pancreatic transplant with worsening glucose\n tolerance.\n\n ULTRASOUND OF THE PANCREAS WAS PERFORMED: There is no evidence of focal\n masses or collections around it. The echogenicity of the pancreas is normal.\n The pancreatic duct is not dilated. Normal vascular flow was noted including\n the arterial and venous parts of it.\n\n IMPRESSION: Normal-appearing pancreatic transplant.\n\n" }, { "category": "ECG", "chartdate": "2190-05-02 00:00:00.000", "description": "Report", "row_id": 152836, "text": "Sinus tachycardia, rate 122. Minor non-specific repolarization changes. No\ndiagnostic abnormality. Compared to the previous tracing of the sinus\nrate is considerably faster and the axis has shifted slightly leftward.\n\n" }, { "category": "ECG", "chartdate": "2190-04-20 00:00:00.000", "description": "Report", "row_id": 152837, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of : right precordial T wave changes decreased\n\n" } ]

[ { "category": "Echo", "chartdate": "2137-09-07 00:00:00.000", "description": "Report", "row_id": 105421, "text": "PATIENT/TEST INFORMATION:\nIndication: Cardiac arrest. Abnormal ECG. Left ventricular function. Myocardial infarction.\nStatus: Inpatient\nDate/Time: at 22:00\nTest: TTE (Focused views)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal anteroseptal - akinetic; mid\nanteroseptal - akinetic; basal inferoseptal - akinetic; mid inferoseptal -\nakinetic; basal inferolateral - hypo; mid inferolateral - hypo; basal\nanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;\nseptal apex- akinetic; inferior apex - hypo; lateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nFOCUSED VIEWS: Overall left ventricular systolic function is severely\ndepressed (LVEF= 15-20 %) with severe global hypokinesis and near-akinesis of\nthe anterior wall, septum, and apex. There is some preservation of function of\nthe basal lateral wall. The right ventricular cavity is mildly dilated with\nmoderate global free wall hypokinesis. The number of aortic valve leaflets\ncannot be determined. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. No mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252806, "text": " 11:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm hem? ptx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 42F ET with vfib arrest and blood form ET tube\n REASON FOR THIS EXAMINATION:\n pulm hem? ptx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old woman with endotracheal tube and V-fib arrest with\n blood from the endotracheal tube. Evaluate for pulmonary hemorrhage or\n pneumothorax.\n\n COMPARISON: No relevant comparison is available. The patient's true identity\n is not known at the time of reporting.\n\n FINDINGS: A frontal supine view of the chest was obtained portably. The\n endotracheal tube ends 1.8 cm above the carina. Diffuse bilateral pulmonary\n opacities may represent infection or hemorrhage in the setting of blood from\n the endotracheal tube. Heart size is normal. Evaluation of the mediastinum is\n limited by overlying trauma board.\n\n IMPRESSION:\n 1. Endotracheal tube ends 1.8 cm above the carina.\n 2. Diffuse bilateral parenchymal opacities may represent infection or\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2137-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252825, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET, OG tube placement, pulm edema\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with v fib arrest s/p resuscitation and pulm hemorrhage from\n ET tube, new OG placement\n REASON FOR THIS EXAMINATION:\n ET, OG tube placement, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube placement and pulmonary edema.\n\n FINDINGS: In comparison with study of , there are again diffuse bilateral\n pulmonary opacifications with differential as previously described.\n Endotracheal tube tip lies approximately 5 cm above the carina. Nasogastric\n tube extends well into a dilated stomach. Swan-Ganz catheter from the IVC has\n its tip in the left pulmonary artery. The aortic device introduced through\n the femoral artery as its tip extending to the standard position in the left\n ventricle.\n\n This information has been discussed with the resident covering for Dr. .\n\n\n" }, { "category": "ECG", "chartdate": "2137-09-08 00:00:00.000", "description": "Report", "row_id": 305259, "text": "Sinus tachycardia with further increase in rate as compared with previous\ntracing of . There is low limb lead voltage. Further evolution of\nacute anterolateral myocardial infarction and new ST segment depression\nin leads II, III and aVF. Followup and clinical correlation are suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2137-09-08 00:00:00.000", "description": "Report", "row_id": 305260, "text": "Sinus tachycardia. Biatrial abnormality. Low limb lead voltage. Further\nevolution and increase in rate as compared with previous tracing of .\nAcute anterolateral myocardial infarction.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2137-09-08 00:00:00.000", "description": "Report", "row_id": 305261, "text": "Sinus tachycardia with slowing of the rate as compared with previous tracing\nof . There is now low limb lead voltage. The axis is no longer leftward\nand there is further evolution of acute anteroseptal and lateral myocardial\ninfarction. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-09-07 00:00:00.000", "description": "Report", "row_id": 305262, "text": "Sinus tachycardia. Left anterior fascicular block. Marked ST segment\nelevation in leads V2-V6 with slight ST segment elevation in leads I and aVL\nand T wave inversion. These findings are consistent with acute anterolateral\nmyocardial infarction. Followup and clinical correlation are suggested.\nNo previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2149-05-28 00:00:00.000", "description": "Report", "row_id": 1308486, "text": "NPN see careview for details\n\nNUERO:Confused w/ visual halucinations,restless, fine motor tremors,mumbles,follows commands inconsistantly,active s/s of detaox requires restraints to prevent trauma recieving ativan per CIWA scale.\n\nResp: coarse lung soundsthroughout,losse productive cough,white/yellow sputum.episode of desat to 70'swhile on 3l nc.Oral pharyngeal sx for presently on cool neb w/ 3lNC sats 100%.\n\nC/V:VSS , Afebrile, SR-ST no ectopy.L sub clav TLC, poor periphreal access\n\nF/E/N: NPO,completed banana bag,presently has NSS @150,UO >50cc/hr,inct of BM X1,normal in color and consistancy.\n\n\nPlan; detox, protect airway,ativan per CIWA,\n" }, { "category": "Nursing/other", "chartdate": "2149-05-28 00:00:00.000", "description": "Report", "row_id": 1308487, "text": "M/SICU Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data.\n\nCNS/Withdrawal from Alcohol and Narcotics: Ativan held per psych as pt. showing evidence of oversedation, i.e. drowsiness, slurred speech. CIWA scale of 4 as pt. continues to be restless and agitated at times. Remains on 4pt. restraints with waist belt for safety. Haldol to be used prn (2.5mg x 1) today. He can inconsistently state where he is and follows simple commands. Improving in that he is able to make appropriate requests, i.e. asking for water, stating he needs to move his bowels.\n\nRESP: Sats of >98% on 40% cool neb. Congested, non-productive cough. Lungs with exp. wheezes throughout...receiving bronchodilator treatments.\n\nCVS: Hemodynamically stable with heart rate 80-100 and SBP of 120-170/systolic.\n\nF and E: Receiving NS at 150cc/hr. U.O. excellent...currently 380cc positive.\n\nSKIN: Intact. Restraints removed q2hr.\n\nSOCIAL: Significant other in this AM and spoke with resident, Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2149-05-28 00:00:00.000", "description": "Report", "row_id": 1308488, "text": "Addendum: In order to manage withdrawal more effectively, librium 50mg IV bid to be started.\n" }, { "category": "Nursing/other", "chartdate": "2149-05-29 00:00:00.000", "description": "Report", "row_id": 1308489, "text": "micu/sicu npn 1900-0700\npatient agitated/restless most of the night, at times screaming at the top of his lungs that he wants to get up and go home, and yelling asking why are we holding him captive. at best patient oriented to self, thinking it's and not knowing where he is, despite frequent reorienting. pt sometimes speaking clearly other times mumbling and difficult to understand. librium unavailable last night ? of getting it this afternoon. valium used last night q 1hour in 5 and 10mg doses, along w/haldol -- will need to use ativan this am though because of the shortage of valium, there is none left in the hospital. pt fidgity and restless or agitated for most of the night despite the benzos and haldol dosages, but finally at ~4am, pt fell asleep, although he continues to be jumpy and restless in his sleep, he has not been agitated. cont to monitor for withdrawal symptoms..?transfer to detox facility in day or so..\n" }, { "category": "Nursing/other", "chartdate": "2149-05-29 00:00:00.000", "description": "Report", "row_id": 1308490, "text": "Please see nursing transfer note and carevue for documentation of today's events.\n" } ]

[ { "category": "ECG", "chartdate": "2114-11-28 00:00:00.000", "description": "Report", "row_id": 191467, "text": "Sinus tachycardia, rate 107. Since the previous tracing of the heart\nrate is faster. No other changes are seen.\n\n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302328, "text": "7a-3p\nneuro: lethargic, easily aroused, follws simple commands, moving all extremites, oriented x 1\n\ncv: hr nsr-st, no ectopy, sbp stable\n\nresp: extubated this am, doing well on 3 l np, sat 96-100, rr 12-20, no resp distress noted, bs+ all lobes , clear, diminished to bases, coughing productively & swollowing sputum\n\ngi: full lix diet, tol fair, no appetite, FIB intact, sm amt liquid brown stool, iv protonix, po carafate\n\ngu: foley patent, clear amber urine, good uo\n\nother: ex-wife in & updated on pt's condition, no other family contact, 1000 labs stable(hct 29, plt 52), bedside abdomonal ultrasound done, hepatic artery/vein without clot\n\nplan: continue to monitor resp/mental status in ICU, abd CT scan this pm to eval liver tumor, labs q 6 hrs today\n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302329, "text": "S. I am in it is \nO. neuro lethagic arousal to voice taking po with encouragement, mae, fc. Receiving lactulose po\ncvs HR 100's ST bp 121/80 Hct 27.2 INR 2.2 plts 41 no s+s of blding on sandostatin 50mcg/hr\nresp 3lnp lungs clear diminished bases o2 sat 99%\nGI went down to CT scan of his liver abd ascites bs+ fecal bag in place draining dark brown stool liq\ngu u/o > 30cc qhr\naccess 20g both hands and rij\na. s/p UGIB\np. will transfer to floor when bed becomes available. Check hct, plts, at 12mn, lactulose as ordered monitor neuro status\n" }, { "category": "Nursing/other", "chartdate": "2114-11-26 00:00:00.000", "description": "Report", "row_id": 1302323, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: NKDA\n\nPt transferred from OSH for TIPS evaluation. Presented to OSH on with complaints of hemataemesis and melena stools x 2 days. GI lavaged for 750cc dark fluid. Electively intubated for EGD. During procedure numerous esophageal varices were visualized and banded. The following day pt had episode of BRBPR and was scoped again, during the procedure the varices were rebanded.\n\nNeuro: Pt previously sedated at OSH on Fentanyl and Versed drips, currently pt is off all sedation adn tolerating well. Goal is to wean sedation so that pt can be extubated.\n\nCV: HR 80-90's NSR with no ectopy noted, BP 100-120/70-80, CVP ~4. Peripheral pulses palpable. Last crit 28.8 up from 27.9, platelets 39, team aware.\n\nResp: Pt intubated, current setting are CPAP+PS 5/5/40%, STV~600-700, MV 8-10L. Latest VBG 7.39/37/44/23. Lung sounds clear in apices, diminished in bases. Suctioned x 1 for scant amounts of clear secretions.\n\nGI: Hypoactive bowel sounds x 4, abdomen soft and distended. Please note pt has not eaten for last 7 days. Rectal bag intact draining liquid brown stool. Octreotide gtt running at 50mcg/hr. Liver team in to evaluate this evening.\n\nGU: Foley patent and draining clear amber urine. UO 30-40cc/hr.\n\nAccess: Pt has PIV x 2, RIJ TLC.\n\nSocial: Family in to visit today, very involved in pt's care. Pt has sister that has just died (this past Thursday) of CA. HCP is sister (H) (, (C) (. Other important phone numbers listed on white board in pt's room. Pt's ex-wife also in to visit, still very close to pt with whom she has 9 year old daughter.\n\nPlan:\nextubate once pt alert and oriented\nmonitor crits\nTIPS evaluation tomorrow?\nmonitor for active signs of bleeding\n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302324, "text": "Respiratory Care\nPt remains intubated on minimal vent support. Pt adm. to unit from OSH had been intubated there for EGD procedure. Pt mental status and ability to protect airway remains a concern, pt briefly opening eyes and moving in bed but not following commands. A.M. RSBI 25 and tol SBT well. Suctioned for tenacious tan-blood tinged secretions. Plan is to extubated today.\n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302325, "text": "MICU Nursing Note 1900-0700\nEvents: Pt remains intubated due to sedated state and ? if able to protect his airway, tolerating CPAP+PS, Paracentesis by MICU team and fluid sent off for cell counts, Transfused with total of 2 units platelets and 1 unit pRBC's overnight. No evidence of bleeding noted but continues to drop HCT.\n\nNeuro: Arouses to painful stimuli and occasionally to verbal stimuli, inconsistent mental status all night, does not follow commands, moves all extremities, opens eyes at times to verbal stimulation and makes eye contact but is unable to sustain and not able to do all of the time, PEARL, will arouse with stimulation briefly and then drifts back off, bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 80-90's SR with no ectopy noted, BP= 120-130's/70-80's, Left IJ TLC site C/D/I (placed at OSH on ), CVP= , IV D5 1/2NS infusing at 100ml/hr.\n\nResp: Lungs essentially clear and diminished at bilat bases, occasionally sounds coarse and clears with suctioning, ETtube suctioned for scant amts thick tan-blood tinged sputum, Suctioned for large thick tan plug x 1, oral suction for small clear sputum, Remains intubated with # 8 ETtube and tolerating CPAP+PS 5/5 at 40 % all night with Sats= 100%, + cough reflex,, TV= 600-700's, MV= , RR= and primarily most of night---willl increase with stimulation. Remains intubated to protect airway while awaiting neuro status to clear.\n\nGI: NPO, no OGtube or NGtube due to s/p banding at OSH, Abd large with ascites and + bowel sounds all quads, Rectal bag intact and draining small amts liquid black stool----guiac +. No N/V. Paracentesis performed by MICU team in left lower quad and fluid sent off for cell counts---no bleeding from site----area C/D/I. Remains on IV Octreotide at 50 mcgs/hr continuous gtt, Hct on adm to MICU 28.8 ( and reported to be 30 yest am at OSH) and dropped to 24.6 at 11pm---transfused with 1 unit pRBC's with new am Hct pending. Pt transfused with 1 unit platelets prior to paracentesis for adm. platelet count of 39----post transfusion platelet count down to 37, so pt transfused with second unit platelets with am level pending at this time.\n\nGU: Foley to CD draining amber clear urine > 30 ml/hr.\n\nSkin: ecchymotic areas noted on upper extremities and small areas on lower extremities, general anasarca, no breakdown noted.\n\nID: afebrile and WBC WNL, on IV Ciprofloxacin.\n\nSocial: sister called during evening and was updated on pt's condition and plan of care by MICU team, MICU resident contact (HCP) and obtained consent for blood transfusions and paracenteses. Family attended pt's sister's wake last evening and will be attending the funeral this am and will come visit pt after ceremony.\n\nPlan: Extubate pt when more alert and able to protect airway, transfuse prn, aggressive pulmonary toilet, monitor for signs of bleeding, hold all sedation, obtain social service consult for family to assist with recent loss and \n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302326, "text": "MICU Nursing Note 1900-0700\n(Continued)\n of pt's condition, Support pt and family, Address nutrition ( ? OG tube insertion for lactulose and other po meds??)\n" }, { "category": "Nursing/other", "chartdate": "2114-11-27 00:00:00.000", "description": "Report", "row_id": 1302327, "text": "respiratory care\npt was on the vent, pt was weaned off tol well. see respoiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2114-11-28 00:00:00.000", "description": "Report", "row_id": 1302330, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVIEW FOR OTHER OBJ DATA\n\n52 YR OLD MALE WITH HX OF HEPC /CIRRHOSIS TO ETOH ABUSE, HEPATIC TRANSFERED FROM OSH AFTER 2 EPISODES OF VARICEAL BLEED FOR EVAL OF .\n\nNO ACUTE EVENT THIS SHIFT\n\nRECEIVED PT / AROUSES ON VOICE/ PRESENTLY, PT BECOMES MORE AWAKE, ALERT, SPONTENEOUS/ OX2, FOLLOWS COMMANDS/ NO PAIN. PEERLA.\n\nHEART RYTHM SINUS TACHY WITH BUNDLE BRANCH BLOCK/ HR 90S-105/ NO ECTOPY. BP 120S-130S. BIL UPPER/LOWER EXT EDEMA 2+ NOTED.\nAFEBRILE: TMAX:98.6/ WBC:8.4/ PT REMAINS ON ANTBX.\nHCT STABLE: 30.7/ 30.0/ PLATELET REMAINS LOW:43/TEAM AWARE PLT GOAL:50.\nS/P EXTUBATION ON IN AM, RESP EFFORT UNLABORED AND EVEN/ LUNG SOUNDS CLEAR IN UPPER AIRWAYS/ DIMINISHED AT BASES/ SATO2 93-96% ON RA.\n\nABD DISTENDED/ POS BM/ INCT STOOL BAG INTACT, DRAINING LARGE AMOUNT OF LIQUID STOOL/ PT REMAINS ON LACTULOSE/ RECEIVED 2 DOSES DURING THIS SHIFT/ ENCOURAGE LACTULOSE INTAKE.\n\nFOLEY PATENT DRAINING AMBER CLEAR URINE/ UOP MARGINAL 20-60CC/HR\n\nSKIN W/D, REPOS FREQUENTLY. PIVSX2/ RIJ TLC INTACT/ WILL BE D/CED THIS AM\n\nFAMILY VISITED AT BEGINNING OF SHIFT\n\nPT C/O SINCE / BUT REMAINS IN OBSERVATION UNTIL THIS AM SOMNOLENCE.\nMONITOR MENT STATUS\nTRANSFER TO FLOOR WHEN PT BECOMES MORE ALERT\n" }, { "category": "Radiology", "chartdate": "2114-11-27 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 940641, "text": " 3:54 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: eval for hcc mass and for anatomy for TIPS consideration\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hcc s/p RFA and variceal bleed; being considered for\n TIPS\n REASON FOR THIS EXAMINATION:\n eval for hcc mass and for anatomy for TIPS consideration\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old man status post RF ablation of hepatocellular carcinoma\n with variceal bleed and being considered for possible TIPS.\n\n Comparison is made to prior CT dated and prior ultrasound\n dated .\n\n CT OF THE ABDOMEN AND PELVIS:\n TECHNIQUE: MDCT acquired axial images were obtained through the abdomen and\n pelvis without oral contrast and with and without intravenous contrast. Portal\n and delayed venous images were obtained per protocol. Coronal and sagittal\n reformats were displayed with 5-mm slice thickness and each show better\n anatomic localization of disease.\n\n CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Limited examination\n of the lung bases displays bilateral dependent atelectasis with a small right-\n sided and slightly larger left-sided pleural effusion. No focal pulmonary\n opacities or nodules are identified. A central venous catheter is noted with\n its tip within the cavoatrial junction. There is evidence of gynecomastia.\n\n Previous RF ablation site within the dome of the liver measures approximately\n 2.7 x 3.5 cm. There is no evidence of local recurrence. A small\n hypoattenuating lesion within the left lobe of the liver appears stable from\n prior examination and displays no evidence of enhancement. Again the liver is\n noted to have a nodular contour and shrunken size consistent with patient's\n history of cirrhosis. There is recanalized umbilical vein. The hepatic veins\n all appear patent. Note is made of a small nonocclusive thrombus extending\n from the portal confluence of the splenic and superior mesenteric veins to the\n bifurcation of the left and right portal veins. This appears grossly stable\n when compared to prior examinations dating back to . The portal\n branches appear patent. Gallbladder contains stones. The spleen is again\n noted to be enlarged, measuring 19cm on coronal images, and contains multiple\n perisplenic varices, and probable splenorenal shunt. Multiple gastric varices\n and small esophageal varices are also identified along with multiple\n collateral vessels along the anterior abdominal wall. The pancreas, adrenal\n glands, and kidneys all appear grossly normal. There is no evidence of\n hydronephrosis bilaterally. There has been interval increase in a moderate\n amount of abdominal ascites. Again identified are multiple enlarged mesenteric\n and retroperitoneal lymph nodes, the largest measuring approximately 2.5 cm\n (series 3B, image 205). There is multiple dilated air and fluid filled loops\n (Over)\n\n 3:54 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: eval for hcc mass and for anatomy for TIPS consideration\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of large bowel with minimal dilatation of the small bowel within the abdomen.\n No free air is noted within the abdomen.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Air is noted within a Foley\n containing urinary bladder. There is air within the rectum and sigmoid colon.\n There is a large amount of free fluid noted within the pelvis. No\n pathologically enlarged pelvic or inguinal lymph nodes are identified.\n\n BONE WINDOWS: No suspicious blastic or lytic lesions are identified. There\n is loss of a normal lumbar lordosis and mild retrolisthesis of L5 on S1.\n Diffuse calcifications are noted within the aorta.\n\n IMPRESSION:\n 1. No evidence of recurrence around RF ablation site or new hepatic lesions.\n 2. Interval increase in abdominal and pelvic ascites. Stable appearance to\n perisplenic varices and multiple collateral vessels with increase in gastric\n and esophageal varices.\n 3. Small nonocclusive chronic thrombus within the main portal vein, grossly\n stable dating back to . Otherwise unremarkable hepatic and\n portal veinous systems.\n 4. Cholelithiasis without evidence of cholecystitis.\n 5. Dilated air and fluid filled colon with minimal dilatation of small bowel.\n No evidence of mechanical obstruction, findings suggestive of ileus.\n\n Findings discussed with covering physician, . on date of exam\n at approximately 5:30 p.m.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2147-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 422946, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Received Lactulose 30ml at 8pm, 2am, 4am\n Received Lactulose 60ml at 6am\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (107 - 132) bpm\n BP: 128/86(96) {112/65(79) - 143/94(99)} mmHg\n RR: 12 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 330 mL\n 860 mL\n PO:\n 800 mL\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 520 mL\n 200 mL\n Urine:\n 520 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -190 mL\n 660 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.54/29/205/23/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows simple commands, no clonus, no asterixis noted\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 23 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n WBC\n 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TCO2\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n # altered mental status: likely secondary to hepatic encephalopathy.\n Per his mother, he has been taking his medications but only having\n about 2 bowel movements per day. DDx also includes infection (CXR clear\n and ascites fluid did not suggest infection and u/a was negative),\n medications (recently started medications for cramping including\n cyclobenzaprine, hyoscyamine and magnesium, some of which may\n contribute to confusion. Was given lactulose in the ED with bowel\n movement afterwards. His mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # primary respiratory alkylosis: likely secondary to anxiety or pain\n and he is tachycardic which supports this idea. He denies pain\n currently. Would like to avoid sedating medications in a patient with\n end stage liver disease as I would like to extubate him tonight.\n -monitor ABGs for now. If alkylosis worsens, may need to lower his RR\n with sedation or try to lower pressure support.\n -will likely improve post extubation\n .\n # nausea and vomiting: likely gastroenteritis or could be from new\n medications for muscle spasms including magnesium which dose was\n recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of \n (current 7)\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -u/s with doppler of the liver\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # pulmonary hypertension: continue iloprost and sildenafil.\n .\n # respiratory support: currently intubated for airway protection given\n altered mental status.\n -consider pressure support trial\n -would like to extubate tonight if mental status improves.\n .\n # hypothyroidism: continue levothyroxine\n .\n # FEN: NPO for now. Hope to extubate. Received IVF in ED.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: ICU for now and likely to floor in AM.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 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": "2147-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 422960, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Received Lactulose 30ml at 8pm, 2am, 4am\n Received Lactulose 60ml at 6am\n This AM, patient is awake and alert, able to respond to questions;\n however somewhat disoriented. Oriented to place and person only;\n however was aware of running for president.\n Pt denies N/V, denies SOB or abdominal pain. Does not remember events\n which precipitated admission.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (107 - 132) bpm\n BP: 128/86(96) {112/65(79) - 143/94(99)} mmHg\n RR: 12 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 330 mL\n 860 mL\n PO:\n 800 mL\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 520 mL\n 200 mL\n Urine:\n 520 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -190 mL\n 660 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.54/29/205/23/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: MMM, no LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended with clinical\n ascites, no tenderness\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows commands, no clonus, no asterixis noted\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 23 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n WBC\n 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TCO2\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n .\n # Altered mental status: likely secondary to hepatic encephalopathy.\n Was given lactulose in the ED with bowel movement afterwards. His\n mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # Primary respiratory alkalosis: now resolved and patient is extubated.\n -continue supportive care\n .\n # Nausea and vomiting: Resolved. Likely gastroenteritis or could be\n from new medications for muscle spasms including magnesium which dose\n was recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # Ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # Elevated WBCs with left shift: concerning for infection although\n peritoneal fluid does not have >250 polys and does not present picture\n of SBP. Pt is afebrile and otherwise asymptomatic.\n - will continue to trend and hold off on abx at this time\n - f/u cultures from peritoneal fluid\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of .\n Currently trending up and is 8.5 this AM. Will f/u with fractionated\n bilirubin.\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # Pulmonary hypertension: continue iloprost and sildenafil.\n .\n # Hypothyroidism: continue levothyroxine\n .\n # FEN: Regular diet with sodium restriction, on home diuretics but\n appears volume overloaded. Replete lytes PRN.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 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": "2147-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 422962, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Received Lactulose 30ml at 8pm, 2am, 4am\n Received Lactulose 60ml at 6am\n This AM, patient is awake and alert, able to respond to questions;\n however somewhat disoriented. Oriented to place and person only;\n however was aware of running for president.\n Pt denies N/V, denies SOB or abdominal pain. Does not remember events\n which precipitated admission.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (107 - 132) bpm\n BP: 128/86(96) {112/65(79) - 143/94(99)} mmHg\n RR: 12 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 330 mL\n 860 mL\n PO:\n 800 mL\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 520 mL\n 200 mL\n Urine:\n 520 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -190 mL\n 660 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.54/29/205/23/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: MMM, no LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended with clinical\n ascites, no tenderness\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows commands, no clonus, no asterixis noted\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 23 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n WBC\n 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TCO2\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n .\n # Altered mental status: likely secondary to hepatic encephalopathy.\n Was given lactulose in the ED with bowel movement afterwards. His\n mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # Primary respiratory alkalosis: now resolved and patient is extubated.\n -continue supportive care\n .\n # Nausea and vomiting: Resolved. Likely gastroenteritis or could be\n from new medications for muscle spasms including magnesium which dose\n was recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # Ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # Elevated WBCs with left shift: concerning for infection although\n peritoneal fluid does not have >250 polys and does not present picture\n of SBP. Pt is afebrile and otherwise asymptomatic.\n - will continue to trend and hold off on abx at this time\n - f/u cultures from peritoneal fluid\n .\n # Anemia: HCT 29.0 today which appears to be baseline and likely from\n chronic liver disease.\n - continue to monitor, transfuse for symptoms or HCT<21.\n .\n # Thrombocytopenia: Platelets 100 this AM. Appears to be baseline and\n likely from chronic liver disease\n - continue to trend, monitor for bleeding\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of .\n Currently trending up and is 8.5 this AM. Will f/u with fractionated\n bilirubin.\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # Pulmonary hypertension: continue iloprost and sildenafil.\n .\n # Hypothyroidism: continue levothyroxine\n .\n # FEN: Regular diet with sodium restriction, on home diuretics but\n appears volume overloaded. Replete lytes PRN.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 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": "2147-10-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 422984, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423167, "text": "41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2147-10-27 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 423181, "text": "Chief Complaint: Code Blue on Floor for 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 41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Patient admitted from: \n History obtained from house officer\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies. Currently on liver transplant\n list (Dr. \n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a\n mean pressure of 8. Notably he had a pulmonary capillary wedge\n pressure of approximately 15 at that time and his cardiac output\n was normal with 6.7 liters per minute, cardiac index of 3.7. His\n pulmonary vascular resistance was nearly normal at 251 and he\n was in sinus rhyth at that time with a heart rate of 90.\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n non contrib\n Occupation: lives with mother\n Drugs: remote\n Tobacco: past\n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 09:02 AM\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: 35.5\nC (95.9\n HR: 106 (97 - 124) bpm\n BP: 119/71(86) {115/69(3) - 119/71(86)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 1,150 mL\n 38 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 1,030 mL\n 390 mL\n Urine:\n 730 mL\n 390 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -352 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,070 (1,070 - 1,070) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: 7.60/23/356/22/2\n Ve: 13.3 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, icteric sclerae\n Head, Ears, Nose, Throat: Normocephalic\n CTA B/l no WRR\n RRR N MRG\n Abd distended and fluid filled. Non tender\n Skin: warm\n Neurologic: Responds to: Not assessed, Oriented (to): x0, Movement: no\n withdrawl to pain. No clonus. Pupils dilated but reactive. + corneals,\n no withdrawl to pain b/l, upgoing toes.\n Labs / Radiology\n 107 K/uL\n 31.0 %\n 10.3 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 20 mg/dL\n 22 mEq/L\n 100 mEq/L\n 4.3 mEq/L\n 131 mEq/L\n 8.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n 06:16 AM\n 08:17 AM\n WBC\n 11.7\n 13.4\n 8.4\n Hct\n 27.9\n 29.0\n 31.0\n Plt\n 94\n 100\n 107\n Cr\n 0.8\n 0.9\n 0.9\n TC02\n 26\n 23\n Glucose\n 100\n 106\n 105\n Other labs: PT / PTT / INR:20.7/45.5/2.0, CK / CKMB / Troponin-T:197//,\n ALT / AST:66/110, Alk Phos / T Bili:165/5.7, Differential-Neuts:76.2 %,\n Lymph:10.5 %, Mono:11.8 %, Eos:0.8 %, Lactic Acid:2.8 mmol/L,\n Albumin:2.6 g/dL, LDH:389 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.0\n mg/dL\n Fluid analysis / Other labs: NH3: pending\n Imaging: CXR :\n Head CT : pending\n Chest CT ; pending\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy,\n will look for intracranial bleed (esp with significant respi alkalosis)\n with head CT vs progressive hepatic encephalopathy vs seizure (unclear\n why he would seize).\n - PS ventilation for now\n - avoid sedation\n - Head and Chest CT\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS:\n - Cont lactulose after placement of OG\n - cont SBP proophylacis\n - Head CT and Chest CT to look for bleed and source of infeciton.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - neurology consult\n - EEG\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO/ lactulose\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Comments:\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: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425040, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n * extubated after MS improved\n * hyponatremic to Na 120 -> restricted PO fluids and re-checked labs\n -> Na 122\n * patient stable overnight\n * still to do: auto cpap v sleep study, consider re-image head\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:42 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: 36.7\nC (98\n HR: 112 (79 - 112) bpm\n BP: 116/67(78) {86/40(51) - 138/82(95)} mmHg\n RR: 16 (9 - 22) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 270 mL\n PO:\n 270 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 135 mL\n Urine:\n 730 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\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 131 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 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": "2147-10-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 423135, "text": "Chief Complaint: respiratory failure\n HPI:\n 41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, who originally presented with altered\n mental status hepatic encephalopathy in the setting of decreased\n BMs. See MICU admit note for further details. There was a\n question of aspiration event and he was intubated for airway protection\n at an OSH ED. At , he had a CXR without focal pulm\n consolidations. He was admitted to the MICU, where his mechanical\n ventilation was rapidly weaned. He had a diagnostic tap of his ascites\n which was negative for SBP. His mental status improved and he was\n called out to the hepatology floor on . He had a therapeutic tap\n on PM with removal of 4 L clear peritoneal fluid; again no SBP.\n .\n On the evening after his transfer, he was found nonresponsive in\n \"puddle of saliva\". Hypoxic to 80s and not clearly protecting his\n airway. A code blue was called at ~ 5am and he was intubated. BP\n 99/60, HR 105. Fingerstick 123. He was transfered to MICU 7 for\n further care. No new meds, no narcotics or benzos prior to transfer.\n Last lactulose dose 60 ml at 5 pm on .\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n Medications at home:\n 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n 2. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times\n a day: Take up to 4 times per day as needed to have bowel\n movements per day.\n 3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID\n 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a\n day: also known as Revatio.\n 5. Iloprost Inhalation\n 6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID as needed for\n cramps.\n 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY\n 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO BID\n 9. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:\n One (1) Tablet, Chewable PO twice a day.\n 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a\n day: Do not take at same time as Ciprofloxacin.\n 11. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as\n needed for insomnia.\n 12. Spironolactone 300 mg Tablet PO DAILY\n 13. Hyoscyamine Sulfate 0.15 mg Tablet Sig: One (1) Tablet PO\n three times a day as needed for cramps.\n 14. Furosemide 40mg \n .\n Medications in house:\n Levothyroxine Sodium 88 mcg PO DAILY\n Omeprazole 20 mg PO BID\n Ciprofloxacin HCl 250 mg PO Q24H\n Rifaximin 200 mg PO TID\n Furosemide 60 mg PO DAILY\n Sildenafil Citrate 25 mg PO TID\n Heparin 5000 UNIT SC TID\n Iloprost *NF* 2.5 mcg Inhalation Nine times a day. pulmonary\n hypertension - not getting due to availability.\n Lactulose 30 mL PO QID\n Spironolactone 150 mg PO DAILY\n Lactulose 30 mL PO Q2H:PRN\n Past medical history:\n Family history:\n Social History:\n - ESLD ETOH/hepC on transplant list, MELD=22 now. known grade 1\n esophageal varices by endoscopy, no h/o GIB. biopsy proven liver\n cirrhosis in .\n - pulmonary hypertension - RHC in showed the PA pressures at\n baseline were 47/30 mmHg with a mean of 35 mmHg. This decreased to\n 40/20 mmHg with a mean of 30 with 100% oxygen, and similarly decreased\n to 40/23 mmHg with a mean of 30 with inhaled NO with an increase in\n cardiac output and decrease in PVR as noted. TR gradient 26 on recent\n echo.\n - hypothyroidism\n - anxiety disorder\n - h/o ETOH and IVDU\n - osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease\n Occupation:\n Drugs: remote history, none currently\n Tobacco: quit smoking this year.\n Alcohol: Quit alcohol use 11 years ago reportedly.\n Other: Lives with his mother.\n Review of systems:\n Constitutional: No(t) Fever\n Integumentary (skin): Jaundice\n Psychiatric / Sleep: encephalopathic\n Flowsheet Data as of 06:32 AM\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: 35.8\nC (96.4\n HR: 101 (97 - 124) bpm\n BP: 131/82(93) {114/70(85) - 141/87(99)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,150 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,030 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 12 cmH2O\n SpO2: 100%\n Ve: 12.7 L/min\n Physical Examination\n General Appearance: jaundiced, sedated/intubated\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, pupils 5->4\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities:Edema: Right: 3+, Left: 3+\n Skin: Not assessed, Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mg/dL\n 23 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A11/5/ 07:51 PM\n \n 10:20 P11/5/ 07:57 PM\n \n 1:20 P11/6/ 04:11 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 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TC02\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Differential-Neuts:81.5 %, Lymph:8.5 %, Mono:8.6 %,\n Eos:1.2 %, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n studies:\n CXR (post intubation): ETT low (~1 cm above carina -> repositioned);\n poor inspiration, overall unchanged.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and echogenic with a nodular contour consistent with the\n patient's known history of cirrhosis. The pancreas is not visualized.\n The gallbladder appears collapsed with a thickened wall. Multiple\n echogenic foci seen within are consistent with shadowing calcified\n gallstones as previously described on prior CT. A stone may possibly be\n within the gallbladder neck. No inhepatic bilary ductal dilation is\n seen. The common bile duct is not completely assessed but proximally\n measures 3mm. The portal vein is patent with hepatopetal flow.\n IMPRESSION:\n Limited study due to marked ascites.\n 1. Cirrhotic, shrunken liver.\n 2. Thickened, collapsed gallbladder with multiple shadowing echogenic\n foci consistent with calcified gallstones. Possible stone within the\n neck. .\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and nodular in contour compatible with history of cirrhosis.\n There is a large amount of abdominal ascites, unchanged compared to the\n study from one day prior. No intra-or extra-hepatic biliary dilatation\n noted. The gallbladder is collapsed and the wall again is noted to be\n relatively thickened. Multiple shadowing echogenic foci fill the\n gallbladder and potentially the gallbladder neck and are compatible\n with gallstones. Overall, this has not changed compared to the study 24\n hours prior. The common bile duct is not dilated and measures 2 mm in\n diameter.\n IMPRESSION:\n 1. Unchanged cirrhotic shrunken liver.\n 2. Unchanged large volume of ascites.\n 3. Persistent, thickened, collapsed gallbladder with multiple stones.\n No evidence of intra- or extra-hepatic biliary dilatation.\n Assessment and Plan\n 41 yo male with ESLD with cirrhosis, pulm HTN, originally admitted\n after being intubated for airway protection from AMS thought to\n hepatic encephalopathy. Now found unresponsive with hypoxia and\n respiratory failure.\n .\n # Respiratory failure: Intubated after found unresponsive. Unclear\n etiology but likely related to encephalopathy/delta MS. \n intubation in 2 days. No hemodynamic compromise.\n - management of altered mental status/encephalopathy below.\n - vent: check ABG and adjust accordingly; AC ventilation for now.\n - VAP precautions\n - sedation with fent/versed for now.\n - Eval for other causes of respiratory distress (other than delta MS);\n checking CXR, infectious workup, check ECG.\n .\n # Encephalopathy/delta MS - likely hepatic encephalopathy.\n Initially suspected to be encephalopathic at home as per mother pt only\n having 2 BM/day. No obvious recent GIB, no evidence of infection (SBP\n ruled out, CXR without infiltrate, urine with 29 WBCs but bloody. Pt\n had been recently started on cyclobenzaprine, mag, and hyoscyamine, and\n trazadone which may have contributed at home. Urine tox neg in ED;\n serum tox checked only for etoh and negative. Flows normal on\n ultrasound.\n - repeat tox screen and infectious workup.\n - f/u peritoneal fluid cultures.\n - Place OGT; lactulose Q1-2H until stools, then Q4-6 hours.\n - avoid sedating medications, try to titrate off fent and versed early\n this AM.\n - guaiac stools.\n - Check head CT this AM given acute change and coagulopathy.\n .\n # Respiratory alkalosis. ABG currently ph 7.56/ pCO2 28. Also noted\n to have alkalosis in the past. ? related to liver disease /cirrhosis.\n - decrease TV on vent vs. trial of PS.\n - Checking serum tox to r/o salicylates.\n .\n # ESLD: ETOH/HepC. +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list. +ascites, no SBP presently.\n Therapeutic para yesterday.\n - continue lactulose/rifaximin as above.\n - ?should he be on nadolol.\n - guaiac stools.\n - hold Lasix and spironolactone this AM given high lactate to ensure BP\n stability; likely restart this PM.\n - continue cipro prophylaxis for SBP.\n .\n # pulmonary HTN: on sildenifil and iloprost at home; concern for\n rebound hypertension given that pt has not been on iloprost inhalers\n for past 2-3 days. .\n - attempting to get iloprost inhalers.\n - continue sildenafil.\n .\n # leukocytosis: +left shift, no obvious source of infection presently,\n could be reactive. no fever. cxr without evidence of aspiration.\n - recheck in MICU\n - check UA/UCx, blood cultures.\n - trend fever curve and wbc.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Retic-ing\n well.\n - guaiac stools.\n - trend HCT.\n .\n # hypothyroidism: TSH was elevated 6.6->4.9, since on 75mcg\n synthroid. increased levothyroxine to 88mcg/qdaily earlier during\n admission.\n ICU Care\n Nutrition:\n Comments: NPO, place OGT\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: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2147-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423136, "text": "Pt transferred to MICU 7 Bed 4 after found diaphoretic and unresponsive\n by 10 RN. Transferred from MICU 6 to 10 yesterday.\n Intubated on floor. Arrived ~0530; Unresponsive initially; began\n awakening during personal care; ALine placed by resident; Bolused with\n Fent 25mcg and Versed 1mg per request of resident during suturing; SR;\n BP stable; Difficult access; LSC anteriorally; rhonchi posterior;\n aeration equal; trachea midline; ETT in place; Brown secretions; ABD\n very distended, semi-firm; hypoactive BS; no NG/OG; Foley placed; amber\n urine; #18 PIV placed RFA; 1^st set of Blood Cx sent; Labs sent; LAC\n PIV from OSH leaking and reinforced with new dressing. IVF KVO and\n Fent/Versed placed at new #18 RFA. Foley #16 placed; 300cc amber urine\n out. Resp changed vent settings to PSV in communication with Resident\n (see ABG). Verbal report provided to RN.\n" }, { "category": "Nutrition", "chartdate": "2147-10-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 423252, "text": "TRANSPLANT NUTRITION\n Subjective\n Pt intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 75.3 kg\n 75.3 kg ( 06:00 AM)\n d/t ascites\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 112\n N/A\n 68(est dry wt)\n 111\n Diagnosis: Encephalopathy\n PMH : ESLD, h/o EtOH abuse, IVDA, Hep C, depression, esp varices,\n anxiety disorder, pulm hypertension, osteoporosis, hypothyroidism\n Food allergies and intolerances: N/A\n Pertinent medications: RISS, Lactulose, rifaximin, Cipro, lansoprazole,\n spironolactone, Lasix, others noted\n Labs:\n Value\n Date\n Glucose\n 105 mg/dL\n 06:16 AM\n Glucose Finger Stick\n 145\n 12:00 PM\n BUN\n 20 mg/dL\n 06:16 AM\n Creatinine\n 0.9 mg/dL\n 06:16 AM\n Sodium\n 131 mEq/L\n 06:16 AM\n Potassium\n 4.3 mEq/L\n 06:16 AM\n Chloride\n 100 mEq/L\n 06:16 AM\n TCO2\n 22 mEq/L\n 06:16 AM\n PO2 (arterial)\n 161 mm Hg\n 12:53 PM\n PO2 (venous)\n 94. mm Hg\n 06:29 AM\n PCO2 (arterial)\n 26 mm Hg\n 12:53 PM\n PCO2 (venous)\n 28 mm Hg\n 06:29 AM\n pH (arterial)\n 7.57 units\n 12:53 PM\n pH (venous)\n 7.56 units\n 06:29 AM\n pH (urine)\n 8.0 units\n 08:07 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:53 PM\n CO2 (Calc) venous\n 26 mEq/L\n 06:29 AM\n Albumin\n 2.6 g/dL\n 06:16 AM\n Calcium non-ionized\n 8.2 mg/dL\n 06:16 AM\n Phosphorus\n 3.0 mg/dL\n 06:16 AM\n Magnesium\n 2.0 mg/dL\n 06:16 AM\n ALT\n 66 IU/L\n 06:16 AM\n Alkaline Phosphate\n 165 IU/L\n 06:16 AM\n AST\n 110 IU/L\n 06:16 AM\n Total Bilirubin\n 5.7 mg/dL\n 06:16 AM\n WBC\n 8.4 K/uL\n 06:16 AM\n Hgb\n 10.3 g/dL\n 06:16 AM\n Hematocrit\n 31.0 %\n 06:16 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/dist/ (+) BS\n Assessment of Nutritional Status\n Pt at risk due to:\n Cirrhosis, current medical condition, needs nutrition support\n Estimated Nutritional Needs based on UBW\n Calories: - 2176kcals/day (28-32kcal/kg)\n Protein: 54-102g/day (0.8-1.5 g/kg)\n Fluid: per team\n Estimation of current intake:\n Inadequate\n Specifics:\n Pt well known to services, followed by me at the Transplant Center, on\n the transplant waiting list. Adm from OSH w/ AMS, intubated and tx to\n floor upon extubation. Found to be unresponsive, w/ hypoxia/resp\n failure. Re-intubated, tx to MICU 7 for mngt.(2^nd intubation in 2\n days).\n S/P therapeutic tap . Rec initiating TF (via post pyloric/NJT for\n better tolerance w/ ascites) to be able to provide pt\ns 100% est\n nutrition needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Rec initiating w/ 10cc/hr of FS Nutren Pulmonary and adv to\n goal of 45cc/hr to provide 1620kcals and 73g prot/day .\n 2. With improved clinical condition, eventual goal would be\n Nutren Pulmonary @60cc/hr to provide 2160kcals and 98g prot/day\n providing higher end of 100% est nutrition needs.\n 3. No residuals w/ PPFT/NJT, monitor tol w/ abd exam.\n 4. Monitor hydration status\n Following closely.\n Pls page w/ questions/concerns #\n 17:35\n" }, { "category": "Nursing", "chartdate": "2147-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424972, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n Hepatic encephalopathy\n Assessment:\n Pt sedated on admission after receiving succs 100/etomidate 14mg for\n intubation, slowly became alert, responsive and following commands, pt\n extubated to 50% face tent, A,A,O x3 upon extubation\n Action:\n received total 60ml lactlose x3, sedation held, FIB placed on\n admission for small amt golden stool\n none since; 1645 pt extubated to\n 50% face tent\n Response:\n A,A,O x3 upon extubation, no response to lactulose, visiting with\n family\n Plan:\n Cont monitor neuro status, lactulose as ordered to stool, MD\ns aware of\n no response to lactulose.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium continues to drift lower - 120 at 1230\n Action:\n Holding diuretics\n Response:\n Repeat Na due at 1800\n Plan:\n Cont to follow\n Consider treating as ordered by MICU team\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n LFT\ns remain elevated\n receiving lactulose\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425197, "text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O alkalosis, respiratory\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2147-10-27 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 423150, "text": "Chief Complaint: Code Blue on Floor for 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 41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Patient admitted from: \n History obtained from house officer\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies. Currently on liver transplant\n list (Dr. \n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a\n mean pressure of 8. Notably he had a pulmonary capillary wedge\n pressure of approximately 15 at that time and his cardiac output\n was normal with 6.7 liters per minute, cardiac index of 3.7. His\n pulmonary vascular resistance was nearly normal at 251 and he\n was in sinus rhyth at that time with a heart rate of 90.\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n non contrib\n Occupation: lives with mother\n Drugs: remote\n Tobacco: past\n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 09:02 AM\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: 35.5\nC (95.9\n HR: 106 (97 - 124) bpm\n BP: 119/71(86) {115/69(3) - 119/71(86)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 1,150 mL\n 38 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 1,030 mL\n 390 mL\n Urine:\n 730 mL\n 390 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -352 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,070 (1,070 - 1,070) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: 7.60/23/356/22/2\n Ve: 13.3 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): x0, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 107 K/uL\n 31.0 %\n 10.3 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 20 mg/dL\n 22 mEq/L\n 100 mEq/L\n 4.3 mEq/L\n 131 mEq/L\n 8.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n 06:16 AM\n 08:17 AM\n WBC\n 11.7\n 13.4\n 8.4\n Hct\n 27.9\n 29.0\n 31.0\n Plt\n 94\n 100\n 107\n Cr\n 0.8\n 0.9\n 0.9\n TC02\n 26\n 23\n Glucose\n 100\n 106\n 105\n Other labs: PT / PTT / INR:20.7/45.5/2.0, CK / CKMB / Troponin-T:197//,\n ALT / AST:66/110, Alk Phos / T Bili:165/5.7, Differential-Neuts:76.2 %,\n Lymph:10.5 %, Mono:11.8 %, Eos:0.8 %, Lactic Acid:2.8 mmol/L,\n Albumin:2.6 g/dL, LDH:389 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.0\n mg/dL\n Fluid analysis / Other labs: NH3: pending\n Imaging: CXR :\n Head CT : pending\n Chest CT ; pending\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy,\n will look for intracranial bleed (esp with significant respi alkalosis)\n with head CT vs progressive hepatic encephalopathy vs seizure (unclear\n why he would seize).\n - PS ventilation for now\n - avoid\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS:\n - Cont lactulose after placement of OG\n - cont SBP proophylacis\n - Head CT and Chest CT to look for bleed and source of infeciton.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n > Thrombocytopenia:\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmo\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO/ lactulose\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Comments:\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: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2147-10-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 423166, "text": "Chief Complaint: respiratory failure\n HPI:\n 41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, who originally presented with altered\n mental status hepatic encephalopathy in the setting of decreased\n BMs and some new medications (trazadone, cyclobenzaprine). See MICU\n admit note for further details. There was a question of\n aspiration event and he was intubated for airway protection at an OSH\n ED. At , he had a CXR without focal pulm consolidations. He was\n admitted to the MICU, where his mechanical ventilation was rapidly\n weaned. He had a diagnostic tap of his ascites which was negative for\n SBP. His mental status improved and he was called out to the\n hepatology floor on . He had a therapeutic tap on PM with\n removal of 4 L clear peritoneal fluid; again no SBP.\n .\n On the evening after his transfer, he was found nonresponsive in\n \"puddle of saliva\". Unclear when last seen normal. Hypoxic to 80s and\n not clearly protecting his airway. A code blue was called at ~ 5am and\n he was intubated. BP 99/60, HR 105. Fingerstick 123. He was\n transfered to MICU 7 for further care. No new meds, no narcotics or\n benzos prior to transfer. Last lactulose dose 60 ml at 5 pm on .\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n Medications at home:\n 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n 2. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times\n a day: Take up to 4 times per day as needed to have bowel\n movements per day.\n 3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID\n 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a\n day: also known as Revatio.\n 5. Iloprost Inhalation\n 6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID as needed for\n cramps.\n 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY\n 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO BID\n 9. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:\n One (1) Tablet, Chewable PO twice a day.\n 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a\n day: Do not take at same time as Ciprofloxacin.\n 11. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as\n needed for insomnia.\n 12. Spironolactone 300 mg Tablet PO DAILY\n 13. Hyoscyamine Sulfate 0.15 mg Tablet Sig: One (1) Tablet PO\n three times a day as needed for cramps.\n 14. Furosemide 40mg \n .\n Medications in house:\n Levothyroxine Sodium 88 mcg PO DAILY\n Omeprazole 20 mg PO BID\n Ciprofloxacin HCl 250 mg PO Q24H\n Rifaximin 200 mg PO TID\n Furosemide 60 mg PO DAILY\n Sildenafil Citrate 25 mg PO TID\n Heparin 5000 UNIT SC TID\n Iloprost *NF* 2.5 mcg Inhalation Nine times a day. pulmonary\n hypertension - not getting due to availability.\n Lactulose 30 mL PO QID\n Spironolactone 150 mg PO DAILY\n Lactulose 30 mL PO Q2H:PRN\n Past medical history:\n Family history:\n Social History:\n - ESLD ETOH/hepC on transplant list, MELD=22 now. known grade 1\n esophageal varices by endoscopy, no h/o GIB. biopsy proven liver\n cirrhosis in .\n - pulmonary hypertension - RHC in showed the PA pressures at\n baseline were 47/30 mmHg with a mean of 35 mmHg. This decreased to\n 40/20 mmHg with a mean of 30 with 100% oxygen, and similarly decreased\n to 40/23 mmHg with a mean of 30 with inhaled NO with an increase in\n cardiac output and decrease in PVR as noted. TR gradient 26 on recent\n echo.\n - hypothyroidism\n - anxiety disorder\n - h/o ETOH and IVDU\n - osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease\n Occupation:\n Drugs: remote history, none currently\n Tobacco: quit smoking this year.\n Alcohol: Quit alcohol use 11 years ago reportedly.\n Other: Lives with his mother.\n Review of systems:\n Constitutional: No(t) Fever\n Integumentary (skin): Jaundice\n Psychiatric / Sleep: encephalopathic\n Flowsheet Data as of 06:32 AM\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: 35.8\nC (96.4\n HR: 101 (97 - 124) bpm\n BP: 131/82(93) {114/70(85) - 141/87(99)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,150 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,030 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 12 cmH2O\n SpO2: 100%\n Ve: 12.7 L/min\n Physical Examination\n General Appearance: jaundiced, sedated/intubated\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, pupils 5->4\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities:Edema: Right: 3+, Left: 3+\n Skin: Not assessed, Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mg/dL\n 23 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A11/5/ 07:51 PM\n \n 10:20 P11/5/ 07:57 PM\n \n 1:20 P11/6/ 04:11 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 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TC02\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Differential-Neuts:81.5 %, Lymph:8.5 %, Mono:8.6 %,\n Eos:1.2 %, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n studies:\n CXR (post intubation): ETT low (~1 cm above carina -> repositioned);\n poor inspiration, overall unchanged.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and echogenic with a nodular contour consistent with the\n patient's known history of cirrhosis. The pancreas is not visualized.\n The gallbladder appears collapsed with a thickened wall. Multiple\n echogenic foci seen within are consistent with shadowing calcified\n gallstones as previously described on prior CT. A stone may possibly be\n within the gallbladder neck. No inhepatic bilary ductal dilation is\n seen. The common bile duct is not completely assessed but proximally\n measures 3mm. The portal vein is patent with hepatopetal flow.\n IMPRESSION:\n Limited study due to marked ascites.\n 1. Cirrhotic, shrunken liver.\n 2. Thickened, collapsed gallbladder with multiple shadowing echogenic\n foci consistent with calcified gallstones. Possible stone within the\n neck. .\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and nodular in contour compatible with history of cirrhosis.\n There is a large amount of abdominal ascites, unchanged compared to the\n study from one day prior. No intra-or extra-hepatic biliary dilatation\n noted. The gallbladder is collapsed and the wall again is noted to be\n relatively thickened. Multiple shadowing echogenic foci fill the\n gallbladder and potentially the gallbladder neck and are compatible\n with gallstones. Overall, this has not changed compared to the study 24\n hours prior. The common bile duct is not dilated and measures 2 mm in\n diameter.\n IMPRESSION:\n 1. Unchanged cirrhotic shrunken liver.\n 2. Unchanged large volume of ascites.\n 3. Persistent, thickened, collapsed gallbladder with multiple stones.\n No evidence of intra- or extra-hepatic biliary dilatation.\n Assessment and Plan\n 41 yo male with ESLD with cirrhosis, pulm HTN, originally admitted\n after being intubated for airway protection from AMS thought to\n hepatic encephalopathy. Now found unresponsive with hypoxia and\n respiratory failure.\n .\n # Respiratory failure: Intubated after found unresponsive. Unclear\n etiology but likely related to encephalopathy/delta MS. \n intubation in 2 days. No hemodynamic compromise.\n - management of altered mental status/encephalopathy below.\n - vent: check ABG and adjust accordingly; AC ventilation for now.\n - VAP precautions\n - Eval for other causes of respiratory distress (other than delta MS);\n checking CXR, infectious workup, check ECG.\n .\n # Encephalopathy/delta MS - likely hepatic encephalopathy.\n Initially suspected to be encephalopathic at home as per mother pt only\n having 2 BM/day. No obvious recent GIB, no evidence of infection (SBP\n ruled out, CXR without infiltrate, urine with 29 WBCs but bloody. Pt\n had been recently started on cyclobenzaprine, mag, and hyoscyamine, and\n trazadone which may have contributed at home. Urine tox neg in ED;\n serum tox checked only for etoh and negative. Flows normal on\n ultrasound.\n - repeat tox screen and infectious workup.\n - f/u peritoneal fluid cultures.\n - Place OGT; lactulose Q1-2H until stools, then Q4-6 hours.\n - avoid sedating medications, titrate off fent and versed early this\n AM.\n - guaiac stools.\n - Check head CT this AM given acute change and coagulopathy.\n - consider eeg - ?could this be seizure.\n - check ammonia to trend.\n .\n # Respiratory alkalosis. ABG currently ph 7.56/ pCO2 28. Also noted\n to have alkalosis in the past. ? related to liver disease /cirrhosis\n and ascites.\n - decrease TV on vent vs. trial of PS.\n - Checking serum tox to r/o salicylates.\n .\n # ESLD: ETOH/HepC. +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list. +ascites, no SBP presently.\n Therapeutic para yesterday.\n - continue lactulose/rifaximin as above.\n - ?should he be on nadolol.\n - guaiac stools.\n - hold Lasix and spironolactone this AM given high lactate to ensure BP\n stability; likely restart this PM.\n - continue cipro prophylaxis for SBP.\n .\n # pulmonary HTN: on sildenifil and iloprost at home; concern for\n rebound hypertension given that pt has not been on iloprost inhalers\n for past 2-3 days. No hemodynamic compromise to suggest that\n respiratory distress was consequence of pulmonary hypertension\n decompensation.\n - attempting to get iloprost inhalers.\n - continue sildenafil.\n .\n # leukocytosis: +left shift, no obvious source of infection presently,\n could be reactive. no fever. cxr without evidence of aspiration.\n - recheck in MICU\n - check UA/UCx, blood cultures.\n - trend fever curve and wbc.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Retic-ing\n well.\n - guaiac stools.\n - trend HCT.\n .\n # hypothyroidism: TSH was elevated 6.6->4.9, since on 75mcg\n synthroid. increased levothyroxine to 88mcg/qdaily earlier during\n admission.\n ICU Care\n Nutrition:\n Comments: NPO, place OGT\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: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2147-11-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 424971, "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: No\n Procedure location: Floor\n Reason: Emergent (1st time)\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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Icu from floor\n am\n no\n Bedside Procedures:\n ABG puncture (10:30)\n Comments:\n Pt intubated emergently on floor for unresponsiveness,no gag. Awoke in\n CCu , easily weaned and extubated.\n" }, { "category": "Respiratory ", "chartdate": "2147-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 423371, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\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: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 2 hrs\n none\n Comments/Plan\n Minimal changes overnight. Pt continues to have large spont\n VT\ns,(900\ns) RSBI=29. See flowsheet for further pt data. Will\n follow.\n 06:06\n" }, { "category": "Physician ", "chartdate": "2147-11-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 424963, "text": "Chief Complaint: respiratory arrest, altered mental status\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 41 yr old man with pHTN ESLD (etoh and hep c) presented initially on\n . On he was in MICU for - intubated, head CT neg, Rx with\n lactulose and cleared and extubated. Negative diagnosic paracentecis\n was negative. Called out to 10. 24 after called out was found\n unresponsive again. Intuabted on floor brought to MICU Green. Chest CT\n neg for PNA or asp. Neuro consult- head CT and MRI- mild abnormality in\n hypothalamuc. 24 hrs in ICU and called back out again. Had done well on\n the floor since then but issues have been management of fluids.\n Restarted aldactone. This am was found unresponsive. ABG: 7.52/24/74 -\n but was intubated for airway protection. Hemodynamics stable. Tx to\n MICU for further management.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 Hep C\n ETOH cirrhosis\n Hypothyroid\n Grade 1 eso varices\n pHTN - on inhaled iloprost and sildenafil\n Meds on Tx:\n Cipro prophy, sc hep, iloprost, lansoprazole, synthroid, rifaximin,\n sildenafil, spironolactone\n F: rheumatic heart disease\n Occupation: diability\n Drugs:\n Tobacco: quit 1 yr ago\n Alcohol: quit 11 yrs ago\n Other: lives with mother\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 93 (93 - 93) bpm\n BP: 138/82(95) {138/82(95) - 138/82(95)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.6 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 17.3 L/min\n Physical Examination\n Gen: intubated, but min responsive\n HEENT: ETT in place,\n CV: RR, nl s1, mildly loud P2\n Chest: CTA bilat\n Abd: distended, =BS not tender\n Ext: no edema\n Neuro: opens eyes to voice and tactile stim, moves ext, slow to\n respond,\n Labs / Radiology\n 127\n 27.4\n 80\n 1\n 27\n 17\n 93\n 3.9\n 120\n 11.2\n [image002.jpg]\n Other labs: PT / PTT / INR://inr 2.2\n ALT 86, AST 148, LDH 340, alk phos 148, t bili 6.1\n Ca 8.1, p 2.1, mg 2.1 alb 2.7\n CXR\n ett 2 cm above carina, low lung volumes, no acute infiltrate or\n volume overload\n Assessment and Plan 41 yr old cirrhotic with altered mental status and\n respiratory failure requiring intubation\n 1. Recurrent AM altered mental status and resp insufficiency:\n DDx has always been hepatic encephalopathy with intermittent lactulose.\n However I wonder about a component of sleep disordered breathing\n with\n his anatomy, abd distension, pHTN\n may be at risk. Would recc formal\n sleep study while in house to eval for this\n need noc ventilation.\n Plan is to switch to PSV, watch closely, lactulose for encephaloathy\n Since he has been imaging head CT x 2 and MRI this admit, and he is\n coming around hold off for now/\n 2. HypoNa: stop the spironolactone for now, trend his Na in \n hrs, if persistently give NS,\n 3. Anemia: near baseline, trend\n 4. pHTN: keep on sildenafil, find out if iloprost can be given\n through vent, if not hold and resume post extubation\n Remaining issues as per Housetaff notes\n ICU Care\n Nutrition: NPO in anticipation of extubation\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Comments:\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: ppi\n VAP: HOB chlorhex,\n Communication: with pt and mother\n status: Full code\n Disposition: ICU\n Total time spent: 45\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425127, "text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy, LFT\ns w/o significant\n change from yesterday\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425129, "text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy, LFT\ns w/o significant\n change from yesterday\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425041, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n * extubated after MS improved\n * hyponatremic to Na 120 -> restricted PO fluids and re-checked labs\n -> Na 122\n * patient stable overnight\n * still to do: auto cpap v sleep study, consider re-image head\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:42 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: 36.7\nC (98\n HR: 112 (79 - 112) bpm\n BP: 116/67(78) {86/40(51) - 138/82(95)} mmHg\n RR: 16 (9 - 22) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 270 mL\n PO:\n 270 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 135 mL\n Urine:\n 730 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n 131 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Recurrent altered mental status: DDX includes infection (less likely\n given this is the third episode in the last few weeks and work up for\n infection has been negative, currently leukocytosis or fevers), stroke\n or head bleed (unlikely for similar reason and prior CT x2 and MRI\n brain all negative), encephalopathy (likely), hyponatremia (could be\n contributing given sodium of 120 is lower than he has been given he\n restarted diuretics yesterday), sleep disorder (given all episodes\n occur first thing in the AM).\n -for hepatic encephalopathy- dose lactulose q2hrs until bowel movements\n then back down with goal bowel movements 5-6 per day, continue\n rifaximine\n -for hyponatremia- repeat labs in 4 hrs. If still hyponatremic, will\n need repletion. Hold diuretics.\n -sleep disorder- continuous oxygen monitoring, ABG when awake and\n extubated for baseline. sleep study needed but may not be able to do in\n house on the weekend. Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # alkylosis: Would think with altered mental status, that his CO2 would\n be high causing an acidosis not alkylosis with low CO2. Could imply a\n sleep disturbance as cause. See above.\n -monitor ABG\n -currently changing to PS ventilation and will resend ABG in 30 mins.\n -ween vent as tolerated.\n -has been extubated quickly on prior episodes.\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil. not be able to get iloprost\n while on vent. Will discuss with respiratory and pharmacy.\n # Hypothyroidism: continue levothyroxine\n # FEN: NPO for now. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 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": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425133, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Abdominal pain (including abdominal tenderness)\n Assessment:\n c/o abdominal pain this AM after receiving lactulose x 24 hours\n with no stool\n Action:\n Abdomen firm, distended, + BS, KUB done early AM - ?ileus vs SBO\n received total 30ml gastroview contrast with 900ml apple juice\n up to\n commode w/1800ml bileus liquid + undigested food; completed w/u per\n team\n abdominal CT negative\n NPO changed to clear lix, lactulose\n restarted at TID\n Response:\n Abdominal distension improved, pain completely relieved, 2^nd episode\n liquid stool\n 800cc\n Plan:\n Continue follow abdominal exam, assess any increased abdominal pain;\n lactulose titrated to stools per day\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy, LFT\ns w/o significant\n change from yesterday\n Action:\n lactulose TID as ordered after changed from NPO to clear lix\n Response:\n Stooled total 2600ml liquid stool this shift\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on room air throughout day, no c/o SOB, tolerating\n standing, OOB to commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow\n Response:\n Tolerated iloprost well with encouragement from brother who was\n visiting after refusing to take this AM\n Plan:\n Continue meds as ordered and assess response.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored\n Response:\n Pt used inhaler x 2 with set up from Resp/RN and assistance from\n brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ improved to 125 this AM\n Action:\n Remains free- H2o restricted\n KCL given in NS at 125/hr x 4 hours;\n will repeat lytes at \n Response:\n Awaiting repeat lytes after K+ infused\n Plan:\n Follow lytes and treat as needed per MICU team.\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425134, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n * extubated after MS improved\n * hyponatremic to Na 120 -> restricted PO fluids and re-checked labs\n -> Na 122\n * patient stable overnight\n * still to do: auto cpap v sleep study, consider re-image head\n * KUB with air-fluid levels\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:42 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: 36.7\nC (98\n HR: 112 (79 - 112) bpm\n BP: 116/67(78) {86/40(51) - 138/82(95)} mmHg\n RR: 16 (9 - 22) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 270 mL\n PO:\n 270 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 135 mL\n Urine:\n 730 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n 131 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: KUB with air fluid levels concerning for SBO and\n patient had no stools x 24 hours. Made NPO including meds & CT scan to\n check for SBO. After drinking contrast patient had large volume stool\n output. CT scan preliminarily no SBO, but ascities present. Abdominal\n pain now resolved after BMs. Will advance diet to clears then as\n tolerated.\n # Recurrent altered mental status: Mental status currently improved.\n DDX includes infection (less likely given this is the third episode in\n the last few weeks and work up for infection has been negative,\n currently no leukocytosis or fevers), stroke or head bleed (unlikely\n for similar reason and prior CT x2 and MRI brain all negative),\n encephalopathy (likely), hyponatremia (could be contributing given\n sodium of 120 is lower than he has been given he restarted diuretics\n yesterday), sleep disorder (given all episodes occur first thing in the\n AM).\n -for hepatic encephalopathy- dose lactulose q2hrs until bowel movements\n then back down with goal bowel movements 5-6 per day, continue\n rifaximine\n -for hyponatremia- improving, hold diuretics, check pm lytes\n -sleep disorder- continuous oxygen monitoring, ABG when awake and\n extubated for baseline. sleep study needed but may not be able to do in\n house on the weekend. Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # alkylosis: Would think with altered mental status, that his CO2 would\n be high causing an acidosis not alkylosis with low CO2. Could imply a\n sleep disturbance as cause. See above.\n -monitor ABG\n -currently changing to PS ventilation and will resend ABG in 30 mins.\n -ween vent as tolerated.\n -has been extubated quickly on prior episodes.\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Clears advance to full liquids for now. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\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": "2147-10-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 423246, "text": "Subjective\n Pt intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 75.3 kg\n 75.3 kg ( 06:00 AM)\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 112\n 68(est dry wt)\n 111\n Diagnosis: Encephalopathy\n PMH : ESLD, h/o EtOH abuse, IVDA, Hep C, depression, esp varices\n Food allergies and intolerances:\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 105 mg/dL\n 06:16 AM\n Glucose Finger Stick\n 145\n 12:00 PM\n BUN\n 20 mg/dL\n 06:16 AM\n Creatinine\n 0.9 mg/dL\n 06:16 AM\n Sodium\n 131 mEq/L\n 06:16 AM\n Potassium\n 4.3 mEq/L\n 06:16 AM\n Chloride\n 100 mEq/L\n 06:16 AM\n TCO2\n 22 mEq/L\n 06:16 AM\n PO2 (arterial)\n 161 mm Hg\n 12:53 PM\n PO2 (venous)\n 94. mm Hg\n 06:29 AM\n PCO2 (arterial)\n 26 mm Hg\n 12:53 PM\n PCO2 (venous)\n 28 mm Hg\n 06:29 AM\n pH (arterial)\n 7.57 units\n 12:53 PM\n pH (venous)\n 7.56 units\n 06:29 AM\n pH (urine)\n 8.0 units\n 08:07 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:53 PM\n CO2 (Calc) venous\n 26 mEq/L\n 06:29 AM\n Albumin\n 2.6 g/dL\n 06:16 AM\n Calcium non-ionized\n 8.2 mg/dL\n 06:16 AM\n Phosphorus\n 3.0 mg/dL\n 06:16 AM\n Magnesium\n 2.0 mg/dL\n 06:16 AM\n ALT\n 66 IU/L\n 06:16 AM\n Alkaline Phosphate\n 165 IU/L\n 06:16 AM\n AST\n 110 IU/L\n 06:16 AM\n Total Bilirubin\n 5.7 mg/dL\n 06:16 AM\n WBC\n 8.4 K/uL\n 06:16 AM\n Hgb\n 10.3 g/dL\n 06:16 AM\n Hematocrit\n 31.0 %\n 06:16 AM\n Current diet order / nutrition support:\n GI:\n Assessment of Nutritional Status\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg)\n Protein: ( g/kg)\n Fluid:\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Comments:\n" }, { "category": "General", "chartdate": "2147-10-27 00:00:00.000", "description": "ICU Event Note", "row_id": 423301, "text": "Clinician: Attending\n Family meeting held. Decision to extubate patient with the\n understanding that she would be unable to survive without mechanical\n ventilation. Patient was bolused with fentanyl and versed for comfort.\n Multiple family members were at bedside.\n Total time spent: 15 minutes\n Patient is critically ill.\n ------ Protected Section ------\n This note was written in error. This pertains to another patient and\n not to .\n ------ Protected Section Addendum Entered By: , MD\n on: 22:47 ------\n ------ Protected Section Error Entered By: , MD\n on: 22:48 ------\n" }, { "category": "General", "chartdate": "2147-10-27 00:00:00.000", "description": "ICU Event Note", "row_id": 423299, "text": "Clinician: Attending\n Family meeting held. Decision to extubate patient with the\n understanding that she would be unable to survive without mechanical\n ventilation. Patient was bolused with fentanyl and versed for comfort.\n Multiple family members were at bedside.\n Total time spent: 15 minutes\n Patient is critically ill.\n" }, { "category": "General", "chartdate": "2147-10-27 00:00:00.000", "description": "ICU Event Note", "row_id": 423300, "text": "Clinician: Attending\n Family meeting held. Decision to extubate patient with the\n understanding that she would be unable to survive without mechanical\n ventilation. Patient was bolused with fentanyl and versed for comfort.\n Multiple family members were at bedside.\n Total time spent: 15 minutes\n Patient is critically ill.\n ------ Protected Section ------\n This note was written in error. This pertains to another patient and\n not to .\n ------ Protected Section Addendum Entered By: , MD\n on: 22:47 ------\n" }, { "category": "Nursing", "chartdate": "2147-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423453, "text": "41 year old male with hx of cirrhosis HCV and EtOH with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably, patient had a neg\n paracentesis for SBP. No evidence of other triggers (infection,\n bleed). Found at 5AM in a \"pool of saliva\", sats in the 80%, with pulse\n and blood pressure, normal finger stick. He was intubated for inability\n to protect airway. By report he had been taking lactulose on the floor.\n Hepatic encephalopathy\n Assessment:\n This AM following commands, able to hold head up. Patient is passing\n large amounts liquid stool per mushroom cath.\n Action:\n Extubated to face tent 35% O2. NGT placed in R nare, receiving\n Lactulose 60ml Q 4 hrs. Nutren pulmonary begun at 10cc/hr.\n Response:\n Mental status clearing, but remains confused. Able to follow commands\n and to converse. Oriented to self and place, confused as to time. Have\n begun to give patient ice chips, seems to be tolerating well.\n Plan:\n Tube feeds and meds per NGT for now until mental status and alertness\n have improved.\n" }, { "category": "Nursing", "chartdate": "2147-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424959, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425126, "text": ".H/O cirrhosis of liver, alcoholic\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy, LFT\ns w/o significant\n change from yesterday\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423435, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\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\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 11:28 ------\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423437, "text": "Chief Complaint:\n 24 Hour Events:\n - Evaluated by neurology who were concerned about RLE weakness and so\n recommended urgent brain MRI, neck MRA.\n - Became progressively tachycardic to 140s which did not respond to\n versed 3 mg, 500 cc fluid bolus, PS 5/5. He responded to fentanyl\n bolus.\n - Ammonia found to be 286\n - Head CT showed ?degenerative disk disease, reccommended lateral film\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:05 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: 37.4\nC (99.4\n HR: 121 (96 - 141) bpm\n BP: 134/85(101) {92/52(66) - 139/85(101)} mmHg\n RR: 11 (10 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 71 mL\n PO:\n TF:\n IVF:\n 948 mL\n 71 mL\n Blood products:\n Total out:\n 835 mL\n 815 mL\n Urine:\n 835 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -745 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 850 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.43/30/431/18/-2\n Ve: 11 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\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: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +ascites\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 123 K/uL\n 10.0 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n In summary, Mr. is an 41 yo male with cirrhosis, pulm HTN,\n admitted for airway protection x 2 in setting of hepatic encephalopathy\n .\n .\n 1. Altered mental status. Patient intubated after an unwitness\n event of unclear etiology on floor (?worsening hepatic encephalopathy,\n large volume para, seizure). Improved with aggressive lactulose with\n good effect overnight and minimizing sedation (boluses of versed and\n fentanyl). Extubated this morning.\n - continue lactulose for >4 BMs/day and improvement of mental\n status\n - ngt placement to allow adequate lactulose intake\n - hold all further mind altering meds\n - monitor mental status\n - r/o infections\n 2. RLE weakness. Continues to have limited RLE weakness in\n spite of increased alertness. Concern for embolic event.\n - f/u MRI brain\n - f/u neck mra\n - neuro following\n 3. Airway. Intubated for airway protection, now extubated.\n 4. Cirrhosis. History of alcohol and Hep C cirrhosis with grade\n 1 varices. ON transplant list. Singnificant abdominal ascites on\n exam, though was tapped for 4 L two days ago.\n - consider para today\n - continue lactulose, lasix, spironolactone\n - continue cipro prophylaxis\n 5. Pulmonary hypertension.\n - ntinue slidenafil\n - hold iloprost for now\n 5. Anemia/thrombocytopenia: baseline hct ~27, plt 70-90..\n - guaiac stools.\n - trend Hct, platelets\n 6. Hypothyroidism. TSH was elevated 6.6->4.9, since on\n 75mcg synthroid. increased levothyroxine to 88mcg/qdaily earlier\n during admission.\n - continue synthroid\n 7. ?degenerative disk disease of cervical spine. Finding noted\n on head CT.\n - consider c-spine imaging when he improves\n clnically\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\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": "2147-11-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 424927, "text": "TITLE:\n Chief Complaint: transferred from floor for altered mental status\n HPI:\n 41 yo M with PMH of pulmonary hypertension, ESLD on transplant list,\n hypothyroidism who is transferred to the ICU for altered mental status.\n He was originially admitted on as a transfer from an OSH. He had\n been found unresponsive by his mother in the morning and brought by EMS\n from the OSH. There he was intubated for airway protection. Head CT was\n negative and futher work up was negative for infection. He was brought\n to the ICU. A diagnostic para was negative for SBP and he was\n given lactulose. He was extubated a few hours after arrival to the ICU\n and called out the floor the next morning. The following day a code\n blue was called for altered mental status around 5am and he was again\n intubated for airway protection. Given lactulose in the ICU. He had\n another head CT and brain MRI which were negative but did show signs of\n hepatic encephalopathy. He was called out the next day to the floor on\n . This stay was complicated by hyponatremia. He was ready for\n discharge on but was kept as his diuretic was started. The plan\n was discharge him on . At around 7am on a code blue was\n called again for altered mental status. A blood gas was drawn and\n morning labs were obtained. He was then intubated for airway protection\n but was never hypoxic. His pulse was in the 80-90 range. SBP was\n 100-120. He was transferred to the ICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n transferred on:\n cipro 250mg IV daily\n lactulose\n spironolactone 100mg daily\n rifaximine\n sildenafil\n iloprost\n lansoprazole\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation: diabled\n Drugs: remote history of IVDU when teenager\n Tobacco: quit last year\n Alcohol: quit 11 years ago\n Other: lives with his mother\n Review of systems:\n Ear, , Throat: OG / NG tube\n Flowsheet Data as of 09:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 93 (93 - 93) bpm\n BP: 138/82(95) {138/82(95) - 138/82(95)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.6 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 979 (979 - 979) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: ///17/\n Ve: 16.8 L/min\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, , Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: pH\n 7.52 pCO2\n 24 pO2\n 74 HCO3\n 20 BaseXS\n 0\n Type:Art\n \n 06:20a\n pH 7.52 pCO2 24 pO2 74 HCO3 20 BaseXS 0\n Type:Art\n 120 93 27 80 AGap=14\n -------------<\n 3.9 17 1.0\n Ca: 8.1 Mg: 2.1 P: 2.1\n ALT: 86 AP: 148 Tbili: 6.1 Alb: 2.7\n AST: 148 LDH: 340\n MCV 99 WBC 11.2 Hgb 9.6 Plt 127\n HCT 27.4\n PT: 22.8 PTT: 61.4 INR: 2.2\n Imaging: CXR: my read: low lung volumes. OG tube in place. ETT about\n 2-3 cm above . No obvious infilatrates or edema\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Recurrent altered mental status: DDX includes infection (less likely\n given this is the third episode in the last few weeks and work up for\n infection has been negative, currently leukocytosis or fevers), stroke\n or head bleed (unlikely for similar reason and prior CT x2 and MRI\n brain all negative), encephalopathy (likely), hyponatremia (could be\n contributing given sodium of 120 is lower than he has been given he\n restarted diuretics yesterday), sleep disorder (given all episodes\n occur first thing in the AM).\n -for hepatic encephalopathy- dose lactulose q2hrs until bowel movements\n then back down with goal bowel movements 5-6 per day, continue\n rifaximine\n -for hyponatremia- repeat labs in 4 hrs. If still hyponatremic, will\n need repletion. Hold diuretics.\n -sleep disorder- continuous oxygen monitoring, ABG when awake and\n extubated for baseline. sleep study needed but may not be able to do in\n house on the weekend. Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # alkylosis: Would think with altered mental status, that his CO2 would\n be high causing an acidosis not alkylosis with low CO2. Could imply a\n sleep disturbance as cause. See above.\n -monitor ABG\n -currently changing to PS ventilation and will resend ABG in 30 mins.\n -ween vent as tolerated.\n -has been extubated quickly on prior episodes.\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil. not be able to get iloprost\n while on vent. Will discuss with respiratory and pharmacy.\n # Hypothyroidism: continue levothyroxine\n # FEN: NPO for now. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423443, "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 URINE CULTURE - At 08:18 AM\n EEG - At 02:46 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n > Markedly improved mental status\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:58 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 (98.5\n HR: 118 (96 - 141) bpm\n BP: 125/74(90) {92/52(66) - 139/85(101)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 180 mL\n PO:\n TF:\n IVF:\n 948 mL\n 80 mL\n Blood products:\n Total out:\n 835 mL\n 985 mL\n Urine:\n 835 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -806 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,026 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.43/30/431/18/-2\n Ve: 7.7 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No acute distress, Thin, icteric\n Eyes / Conjunctiva: PERRL\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended, large\n ascites\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2, Movement: Purposeful, not able to move the\n right leg and increasd patellar reflex on the right. Downgoing toes\n bilateral,\n Labs / Radiology\n 10.0 g/dL\n 123 K/uL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n CXR : improved lung volumes compared to . no obvious\n infiltrate.\n Sputum : GPR and GPC in pairs and chains\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He is markedly improved this\n morning.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Restart lasix and spironolactone\n - Will likely need a repeat paracentesis in the near future will confer\n with liver service.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K for 3 day\n - F/ read of the MRI\n > Right leg weakness: Neuro team concerned for right leg weakness, will\n f/u MRI/A still with decreased right leg . Appreciate neurology input:\n he still has some right lower leg weakness\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO when able\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots, INR 2.0\n Stress ulcer: PPI\n VAP: HOB elevation, Aspiration precautions.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423578, "text": "Hepatic encephalopathy\n Assessment:\n Pt much more alert, moving all extremeties and turning in bed with\n minimal assistance. Pt alert and oriented x 2 needs to be reminded occ\n of where he is. Pt no longer has rectal tube in place, pt able to call\n for bedpan in time. Pt freq asking for ice. Pt\ns abd drainage bag\n draining copious amt\ns of straw colored fluid.\n Action:\n Pt reoriented to time and place and plan of care. Pt thinks he is going\n home tomorrow. Pt cont to take Lactulose q 4/hrs. cont on tube feeding\n at 10cc/hr,\n Response:\n Pt tolerating Lactulose, stooling infreq onbedpan.\n Plan:\n Cont to keep pt oriented, cont with Lactulose.\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423709, "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 > Improved mental status\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 08:11 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 (96.9\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 753 mL\n PO:\n 250 mL\n TF:\n 100 mL\n 82 mL\n IVF:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 4,095 mL\n 2,000 mL\n Urine:\n 1,295 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,247 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96% RA\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: icterus\n Head, Ears, Nose, Throat: NG tube\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: (Breath Sounds: Diminished: bases bilateral)\n Abdominal: Soft, Non-tender, Distended, large ascites with active leak\n from prev tap site. .\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful, Tone: Normal. Right\n leg strength intact\n Labs / Radiology\n 9.2 g/dL\n 104 K/uL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, /L,\n Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.9\n mg/dL\n CXR : improved lung volumes.\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He has now improved to his\n baseline.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Lasix and spironolactone\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K (cont for now)\n - he may need a stitch at the paracentesis site (will d/w liver)\n > Anemia: unexplained drop in Hct. No evidence of hemolysis (LDH\n trending down). Will recheck HCT now. He has been guiace negative.\n There was a report of pink colored ascites yesterday, possibly\n contributing to lower Hct.\n - Recheck Hct (if conts low will need to more actively reverse INR)\n > Right leg weakness: Neuro team concerned for right leg weakness, the\n MRI/A has revealed chronic changes. The right lower weakness has\n resolved\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n Counts have been stable.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour. Can likely\n take PO today (will leave NG inplace).\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor (liver team)\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425008, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended w/ acities. Pt c/o of increasing abd discomfort,\n pressure and cramping. Receiving lactulose, no Bm at this time. Pt\n tossing and turning in bed\n Action:\n Pt turned and repositioned for comfort. Dr. in to evaluate pt. KUB\n ordered. Oxycodone for discomfort.\n Response:\n Plan:\n Possible paracenthesis today.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat Na+ 122, restricting H20, pt c/o feeling thirsty.\n Action:\n Maintain fluid restriction. Taking juice judiciously. Repeat lytes in\n am.\n Response:\n Plan:\n Continue fluid /water restriction, follow electrolytes.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425273, "text": "Addendum to CCU Nursing Transfer Note:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site . Dressing intact and can stay in place\n for 3 days, due to be changed . New Versiva dressing sent with\n patient.\n" }, { "category": "Respiratory ", "chartdate": "2147-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 425274, "text": "Demographics\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 Plan\n Pt followed by respiratory for inhaled Iloprost medication Q2 hrs. Pt\n treated x1 by this RT. PT is planning for discharge to 10. Will\n cont to follow patient and assist with inhalation therapy as needed.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425280, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had large\n bilious liq stool +undigested food. CT Scan reportedly negative for\n SBO.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, + bowel sounds. Pt w/o further\n Abd pain since multiple stools. Some discomfort from ascities.\n Action:\n Continues on lactulose tid. Position change s\ns for comfort.\n Response:\n Able to tolerate advancement of diet.\n Plan:\n Lactulose tid, monitor stools, assess abd and bowel sounds. Continue\n to adjust position for comfort\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow. RT\n assisting with iloprost inhaler. Baseline ABG obtained today:\n 7.45/28/87/20/-2. BP 88-125/49-72, HR 85-102 NSR/ST.\n Response:\n Sats stable on room air.\n Plan:\n Continue meds as ordered , reinforce rationale for medications.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored.\n Response:\n Pt used inhaler with set up from Resp/RN and assistance from brother\n :\n Cont mediction ~Q 2hr w/a; mother brings in fresh supplies from home.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction reduced to 1000cc\ns. Patient informed as well\n as rationale. Given mouth moisturizer.\n Response:\n Pt complying with fluid restriction.\n Plan:\n Follow lytes , continue with FR, enc use of mouth moisturizer.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium. Unclear as to etio of 3 episodes of unresponsiveness since\n admission. w/u includes: correct hyponatremia, continue on lactulose\n for encephalopathy and sleep studies to r/o OSA.\n Action:\n Lactulose tid, follow mental status. Assessing sats and resp status\n closely\n Response:\n A&O X3. No apnea or Sat drop when asleep.\n Plan:\n Lactulose as ordered , continue to folloiw mental status. Continue to\n assess RR and sat when sleeping. For sleep study.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n Admission weight:\n 78.6 kg\n Daily weight:\n 69.9 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; osteoporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:57\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 300 mL\n 24h total out:\n 400 mL\n Pertinent Lab Results:\n Sodium:\n 124 mEq/L\n 09:07 AM\n Potassium:\n 4.1 mEq/L\n 04:42 AM\n Chloride:\n 98 mEq/L\n 04:42 AM\n CO2:\n 20 mEq/L\n 04:42 AM\n BUN:\n 22 mg/dL\n 04:42 AM\n Creatinine:\n 0.8 mg/dL\n 04:42 AM\n Glucose:\n 105 mg/dL\n 04:42 AM\n Hematocrit:\n 27.9 %\n 04:42 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:\n Transferred to:\n Date & time of Transfer:\n ------ Protected Section ------\n Addendum: patient\ns nebulizer and supplies given to patient\ns mother\n for transport to 10. Pt transported from CCU to 10 at 12\n noon on .\n ------ Protected Section Addendum Entered By: , RN\n on: 12:31 ------\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425177, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Abdominal pain (including abdominal tenderness)\n Assessment:\n No further abd discomfort . abd less distended. amt of acites\n present. Up to commode for 800cc of liq stool\n Action:\n Evening dose of lacutose held. MDs aware.\n Response:\n Additional bm very small.\n Plan:\n Continue lacturlose in am.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pm labs w/ Na+122, K+3.6, slt metabolic acidosis.\n Action:\n Potassium replaced. Pt on 1500cc fluid restriction. Clr liq diet D/C\n restarted on solids.\n Response:\n Plan:\n Continue 1500cc fluid restriction.\n Hepatic encephalopathy\n Assessment:\n Alert and oriented. Tired and feeling sleepy due to not sleeping Sat\n pm.\n Action:\n Continue lactulose in am.\n Response:\n Last 24hrs w/ 3300ccof liq stool.\n Plan:\n Follow for any alertations in mental statur.\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423641, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 08:11 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 (96.9\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 753 mL\n PO:\n 250 mL\n TF:\n 100 mL\n 82 mL\n IVF:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 4,095 mL\n 2,000 mL\n Urine:\n 1,295 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,247 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: icterus\n Head, Ears, Nose, Throat: NG tube\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: (Breath Sounds: Diminished: bases bilateral)\n Abdominal: Soft, Non-tender, Distended, large ascites\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.2 g/dL\n 104 K/uL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He is markedly improved this\n morning.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Restart lasix and spironolactone\n - need a repeat paracentesis in the near future will confer with\n liver service.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K for 3 day\n > Right leg weakness: Neuro team concerned for right leg weakness, will\n f/u MRI/A (no evidence of acute process) still with decreased right leg\n . Appreciate neurology input: he still has some right lower leg\n weakness\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 425243, "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 large BM and CT scan without evidence of obstruction\n History obtained from Medical records\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 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 Flowsheet Data as of 08:46 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: 96 (85 - 113) bpm\n BP: 103/53(65) {88/37(50) - 136/72(84)} mmHg\n RR: 9 (9 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 2,590 mL\n 240 mL\n PO:\n 1,990 mL\n 240 mL\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 3,670 mL\n 240 mL\n Urine:\n 1,070 mL\n 240 mL\n NG:\n Stool:\n 2,600 mL\n Drains:\n Balance:\n -1,080 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\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:\n Diminished: )\n Abdominal: Soft, Distended\n Extremities: Right: 2+, Left: 2+\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 123 K/uL\n 105 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 98 mEq/L\n 122 mEq/L\n 27.9 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 41 yo male with known history of cirrhosis and now s/p extubation and\n with rapid move to extubation and now with improving mental status in\n the setting of lactulose therapy and return to active bowel movements.\n Encephalopathy-\n -Lactulose continuing\n -Monitor bowel movement frequency\n -No evidence of new or evolving infection\n Ascites-\n -Cipro to continue for prophylaxis\n -Tap of fluid for any recurrent fevers seen\n Respiratory Failure-\n -Monitor O/N with limited PSG upon the floor\n -In the setting of pulmonary HTN hypoxemia may be worsened and there is\n not clear diagnosis or exclusion of hepato-pulmonary syndrome\n -REM sleep may be an area of vulnerability and full night sleep study\n would be of interest\n -BIPAP if worsening seen\n Pulmonary Hypertension-\n -Likely porto-pulmonary HTN\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:29 PM\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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423654, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 08:11 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 (96.9\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 753 mL\n PO:\n 250 mL\n TF:\n 100 mL\n 82 mL\n IVF:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 4,095 mL\n 2,000 mL\n Urine:\n 1,295 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,247 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96% RA\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: icterus\n Head, Ears, Nose, Throat: NG tube\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: (Breath Sounds: Diminished: bases bilateral)\n Abdominal: Soft, Non-tender, Distended, large ascites with active leak.\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful, Tone: Normal. Right\n leg strength intact\n Labs / Radiology\n 9.2 g/dL\n 104 K/uL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, /L,\n Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.9\n mg/dL\n CXR : improved lung volumes.\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He has now improved to his\n baseline.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Lasix and spironolactone\n - need a repeat paracentesis in the near future will confer with\n liver service.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K (cont for now)\n - he may need a stitch at the paracentesis site (will d/w liver)\n > Anemia: unexplained drop in Hct. No evidence of hemolysis (LDH\n trending down). Will recheck HCT now. He has been guiace negative.\n There was a report of pink colored ascites yesterday, possibly\n contributing to lower Hct.\n - Recheck Hct (if conts low will need to more actively reverse INR)\n > Right leg weakness: Neuro team concerned for right leg weakness, the\n MRI/A has revealed chronic changes. The right lower weakness has\n resolved\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n Counts have been stable.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour. Can likely\n take PO today (will leave NG inplace).\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor (liver source)\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423670, "text": "Chief Complaint: respiratory failure and encephalopathy\n 24 Hour Events:\n MRA head (-)\n MRI head showed small vessel disease, basal ganglia changes c/w\n encephalopathy, no acute ischemia\n NGT placed, lactulose initiated, tube feeds initiated\n Held off on paracentesis as per liver recs\n No neuro recs\n Asking for something to eat/drink\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:52 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: 36.4\nC (97.6\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 337 mL\n PO:\n TF:\n 100 mL\n 78 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 4,095 mL\n 1,970 mL\n Urine:\n 1,295 mL\n 170 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,633 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General: Alert, oriented to name, place, year . Significantly less\n encephalopathic\n HEENT: scleral icterus\n Lungs: CTA biiat. Heart: RRR, S1 S2 slightly tachy\n Abdomen: +BS, only small lower area of dullness, decreased in size.\n Bag overlying past para site, draining clear straw colored fluid.\n Extrem: + pitting edema.\n Neuro: RLE strength 5/5\n Labs / Radiology\n 104 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Mr. is an 41 yo male with cirrhosis, pulm HTN, admitted for\n airway protection x 2 in setting of hepatic encephalopathy .\n .\n 1. Altered mental status. Patient intubated after an unwitness\n event of unclear etiology on floor (?worsening hepatic encephalopathy,\n large volume para, seizure). Improved with aggressive lactulose with\n good effect overnight and minimizing sedation (boluses of versed and\n fentanyl). Extubated early yesterday.\n - continue lactulose for >4 BMs/day and improvement of mental\n status. Change to PO.\n - hold all further mind altering meds\n - Infectious workup\n - Guaiac stools.\n 2. ?RLE weakness. Concern that was not withdrawing to pain;\n now that alert has full strength. Did have MRI which was\n unremarkable.\n - neuro following, appreciate recs.\n 3. Airway. Intubated for airway protection, now extubated.\n 4. Cirrhosis. History of alcohol and Hep C cirrhosis with grade\n 1 varices. ON transplant list. Singnificant abdominal ascites on\n exam, though was tapped for 4 L two days ago. Continues to drain from\n that site > 2 L overnight.\n - continue lactulose, lasix, spironolactone\n - continue cipro prophylaxis\n - Consider suture to para site, will d/w liver.\n 5. Pulmonary hypertension.\n - continue slidenafil and iloprost.\n 6. Anemia/thrombocytopenia: baseline hct ~27, plt 70-90..\n Drop in hct since yesterday, but was 29 the prior day.\n - guaiac stools.\n - trend Hct, platelets\n 7. Hypothyroidism. TSH was elevated 6.6->4.9, since on 75mcg\n synthroid. increased levothyroxine to 88mcg/qdaily earlier during\n admission.\n - continue synthroid\n 8. ?degenerative disk disease of cervical spine. Finding noted on\n head CT.\n - consider c-spine imaging when he improves\n clnically\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour, change to\n oral diet as long as no swallowing issues\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n can remove\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423671, "text": "Chief Complaint: respiratory failure and encephalopathy\n 24 Hour Events:\n MRA head (-)\n MRI head showed small vessel disease, basal ganglia changes c/w\n encephalopathy, no acute ischemia\n NGT placed, lactulose initiated, tube feeds initiated\n Held off on paracentesis as per liver recs\n No neuro recs\n Asking for something to eat/drink\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:52 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: 36.4\nC (97.6\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 337 mL\n PO:\n TF:\n 100 mL\n 78 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 4,095 mL\n 1,970 mL\n Urine:\n 1,295 mL\n 170 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,633 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General: Alert, oriented to name, place, year . Significantly less\n encephalopathic\n HEENT: scleral icterus\n Lungs: CTA biiat. Heart: RRR, S1 S2 slightly tachy\n Abdomen: +BS, only small lower area of dullness, decreased in size.\n Bag overlying past para site, draining clear straw colored fluid.\n Extrem: + pitting edema.\n Neuro: RLE strength 5/5\n Labs / Radiology\n 104 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Mr. is an 41 yo male with cirrhosis, pulm HTN, admitted for\n airway protection x 2 in setting of hepatic encephalopathy .\n .\n 1. Altered mental status. Patient intubated after an unwitness\n event of unclear etiology on floor (?worsening hepatic encephalopathy,\n large volume para, seizure). Improved with aggressive lactulose with\n good effect overnight and minimizing sedation (boluses of versed and\n fentanyl). Extubated early yesterday.\n - continue lactulose for >4 BMs/day and improvement of mental\n status. Change to PO.\n - hold all further mind altering meds\n - Infectious workup\n - Guaiac stools.\n 2. ?RLE weakness. Concern that was not withdrawing to pain;\n now that alert has full strength. Did have MRI which was\n unremarkable.\n - neuro following, appreciate recs.\n 3. Airway. Intubated for airway protection, now extubated.\n 4. Cirrhosis. History of alcohol and Hep C cirrhosis with grade\n 1 varices. ON transplant list. Singnificant abdominal ascites on\n exam, though was tapped for 4 L two days ago. Continues to drain from\n that site > 2 L overnight.\n - continue lactulose, lasix, spironolactone\n - continue cipro prophylaxis\n - Consider suture to para site, will d/w liver.\n 5. Pulmonary hypertension.\n - continue slidenafil and iloprost.\n 6. Anemia/thrombocytopenia: baseline hct ~27, plt 70-90..\n Drop in hct since yesterday, but was 29 the prior day.\n - guaiac stools.\n - trend Hct, platelets\n 7. Hypothyroidism. TSH was elevated 6.6->4.9, since on 75mcg\n synthroid. increased levothyroxine to 88mcg/qdaily earlier during\n admission.\n - continue synthroid\n 8. ?degenerative disk disease of cervical spine. Finding noted on\n head CT.\n - consider c-spine imaging when he improves\n clnically\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour, change to\n oral diet as long as no swallowing issues\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n can remove\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2147-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 423674, "text": "41 year old male with hx of cirrhosis HCV and EtOH with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably, patient had a neg\n paracentesis for SBP. No evidence of other triggers (infection,\n bleed). Found at 5AM in a \"pool of saliva\", sats in the 80%, with pulse\n and blood pressure, normal finger stick. He was intubated for inability\n to protect airway. By report he had been taking lactulose on the floor.\n Hepatic encephalopathy\n Assessment:\n Patient is very much improved, alert and interactive with staff and\n family. He is tolerating PO well. Oriented x2-3.\n Action:\n Extubated to face tent 35% O2 . today weaned to room air. NGT\n removed as patient advanced to regular diet, able to swallow pills.\n Receiving Lactulose 60ml Q 4 hrs.\n Response:\n Mental status continues to clear, appears to be approaching his\n baseline.\n Plan:\n Continue increased dosing of lactulose, do not miss . Goal of\n 4 BMs per day. Monitor mental status closely.\n Patient\ns paracentisis tap site on L abdomen has been draining copious\n amounts of fluid. Drainage bag placed over site, and connected to\n gravity drain. 2, 450cc drained since yesterday evening. MD aware,\n probably will be sutured soon.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 75.3 kg\n Daily weight:\n 75.3 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; ostroporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:69\n Temperature:\n 97.4\n Arterial BP:\n S:145\n D:77\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 109 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,256 mL\n 24h total out:\n 3,230 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:38 AM\n Potassium:\n 3.3 mEq/L\n 04:38 AM\n Chloride:\n 106 mEq/L\n 04:38 AM\n CO2:\n 21 mEq/L\n 04:38 AM\n BUN:\n 22 mg/dL\n 04:38 AM\n Creatinine:\n 0.8 mg/dL\n 04:38 AM\n Glucose:\n 103 mg/dL\n 04:38 AM\n Hematocrit:\n 27.9 %\n 04:38 AM\n Finger Stick Glucose:\n 141\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: Mother\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-784\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423678, "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 > Improved mental status\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 08:11 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 (96.9\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 753 mL\n PO:\n 250 mL\n TF:\n 100 mL\n 82 mL\n IVF:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 4,095 mL\n 2,000 mL\n Urine:\n 1,295 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,247 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96% RA\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: icterus\n Head, Ears, Nose, Throat: NG tube\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: (Breath Sounds: Diminished: bases bilateral)\n Abdominal: Soft, Non-tender, Distended, large ascites with active leak\n from prev tap site. .\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful, Tone: Normal. Right\n leg strength intact\n Labs / Radiology\n 9.2 g/dL\n 104 K/uL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, /L,\n Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.9\n mg/dL\n CXR : improved lung volumes.\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He has now improved to his\n baseline.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Lasix and spironolactone\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K (cont for now)\n - he may need a stitch at the paracentesis site (will d/w liver)\n > Anemia: unexplained drop in Hct. No evidence of hemolysis (LDH\n trending down). Will recheck HCT now. He has been guiace negative.\n There was a report of pink colored ascites yesterday, possibly\n contributing to lower Hct.\n - Recheck Hct (if conts low will need to more actively reverse INR)\n > Right leg weakness: Neuro team concerned for right leg weakness, the\n MRI/A has revealed chronic changes. The right lower weakness has\n resolved\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n Counts have been stable.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour. Can likely\n take PO today (will leave NG inplace).\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor (liver team)\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425257, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had large\n bilious liq stool +undigested food. CT Scan reportedly negative for\n SBO.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, + bowel sounds. Pt w/o further\n Abd pain since multiple stools. Some discomfort from acities.\n Action:\n Continues on lactulose tid.\n Response:\n Able to tolerate advancement of diet.\n Plan:\n Lactulose tid, monitor stools, assess abd and bowel sounds.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow. RT\n assisting with iloprost inhaler. Baseline ABG obtained today:\n 7.45/28/87/20/-2.\n Response:\n Sats stable on room air.\n Plan:\n Continue meds as ordered , reinforce rationale for medications.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored.\n Response:\n Pt used inhaler with set up from Resp/RN and assistance from brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction reduced to 1000cc\ns. Patient informed as well\n as rationale. Given mouth moisturizer.\n Response:\n Pt complying with fluid restriction.\n Plan:\n Follow lytes , continue with FR, enc use of mouth moisturizer.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium. Unclear as to etio of 3 episodes of unresponsiveness since\n admission. w/u includes: correct hyponatremia, continue on lactulose\n for encephalopathy and sleep studies to r/o OSA.\n Action:\n Lactulose tid, follow mental status. Assessing sats and resp status\n closely\n Response:\n A&O X3. No apnea or Sat drop when asleep.\n Plan:\n Lactulose as ordered , continue to folloiw mental status. Continue to\n assess RR and sat when sleeping. For sleep study.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425263, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had large\n bilious liq stool +undigested food. CT Scan reportedly negative for\n SBO.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, + bowel sounds. Pt w/o further\n Abd pain since multiple stools. Some discomfort from ascities.\n Action:\n Continues on lactulose tid. Position change s\ns for comfort.\n Response:\n Able to tolerate advancement of diet.\n Plan:\n Lactulose tid, monitor stools, assess abd and bowel sounds. Continue\n to adjust position for comfort\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow. RT\n assisting with iloprost inhaler. Baseline ABG obtained today:\n 7.45/28/87/20/-2.\n Response:\n Sats stable on room air.\n Plan:\n Continue meds as ordered , reinforce rationale for medications.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored.\n Response:\n Pt used inhaler with set up from Resp/RN and assistance from brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction reduced to 1000cc\ns. Patient informed as well\n as rationale. Given mouth moisturizer.\n Response:\n Pt complying with fluid restriction.\n Plan:\n Follow lytes , continue with FR, enc use of mouth moisturizer.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium. Unclear as to etio of 3 episodes of unresponsiveness since\n admission. w/u includes: correct hyponatremia, continue on lactulose\n for encephalopathy and sleep studies to r/o OSA.\n Action:\n Lactulose tid, follow mental status. Assessing sats and resp status\n closely\n Response:\n A&O X3. No apnea or Sat drop when asleep.\n Plan:\n Lactulose as ordered , continue to folloiw mental status. Continue to\n assess RR and sat when sleeping. For sleep study.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425264, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had large\n bilious liq stool +undigested food. CT Scan reportedly negative for\n SBO.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, + bowel sounds. Pt w/o further\n Abd pain since multiple stools. Some discomfort from ascities.\n Action:\n Continues on lactulose tid. Position change s\ns for comfort.\n Response:\n Able to tolerate advancement of diet.\n Plan:\n Lactulose tid, monitor stools, assess abd and bowel sounds. Continue\n to adjust position for comfort\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow. RT\n assisting with iloprost inhaler. Baseline ABG obtained today:\n 7.45/28/87/20/-2.\n Response:\n Sats stable on room air.\n Plan:\n Continue meds as ordered , reinforce rationale for medications.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored.\n Response:\n Pt used inhaler with set up from Resp/RN and assistance from brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction reduced to 1000cc\ns. Patient informed as well\n as rationale. Given mouth moisturizer.\n Response:\n Pt complying with fluid restriction.\n Plan:\n Follow lytes , continue with FR, enc use of mouth moisturizer.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium. Unclear as to etio of 3 episodes of unresponsiveness since\n admission. w/u includes: correct hyponatremia, continue on lactulose\n for encephalopathy and sleep studies to r/o OSA.\n Action:\n Lactulose tid, follow mental status. Assessing sats and resp status\n closely\n Response:\n A&O X3. No apnea or Sat drop when asleep.\n Plan:\n Lactulose as ordered , continue to folloiw mental status. Continue to\n assess RR and sat when sleeping. For sleep study.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425271, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had large\n bilious liq stool +undigested food. CT Scan reportedly negative for\n SBO.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, + bowel sounds. Pt w/o further\n Abd pain since multiple stools. Some discomfort from ascities.\n Action:\n Continues on lactulose tid. Position change s\ns for comfort.\n Response:\n Able to tolerate advancement of diet.\n Plan:\n Lactulose tid, monitor stools, assess abd and bowel sounds. Continue\n to adjust position for comfort\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow. RT\n assisting with iloprost inhaler. Baseline ABG obtained today:\n 7.45/28/87/20/-2. BP 88-125/49-72, HR 85-102 NSR/ST.\n Response:\n Sats stable on room air.\n Plan:\n Continue meds as ordered , reinforce rationale for medications.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored.\n Response:\n Pt used inhaler with set up from Resp/RN and assistance from brother\n :\n Cont mediction ~Q 2hr w/a; mother brings in fresh supplies from home.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction reduced to 1000cc\ns. Patient informed as well\n as rationale. Given mouth moisturizer.\n Response:\n Pt complying with fluid restriction.\n Plan:\n Follow lytes , continue with FR, enc use of mouth moisturizer.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium. Unclear as to etio of 3 episodes of unresponsiveness since\n admission. w/u includes: correct hyponatremia, continue on lactulose\n for encephalopathy and sleep studies to r/o OSA.\n Action:\n Lactulose tid, follow mental status. Assessing sats and resp status\n closely\n Response:\n A&O X3. No apnea or Sat drop when asleep.\n Plan:\n Lactulose as ordered , continue to folloiw mental status. Continue to\n assess RR and sat when sleeping. For sleep study.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n Admission weight:\n 78.6 kg\n Daily weight:\n 69.9 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; osteoporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:57\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 300 mL\n 24h total out:\n 400 mL\n Pertinent Lab Results:\n Sodium:\n 124 mEq/L\n 09:07 AM\n Potassium:\n 4.1 mEq/L\n 04:42 AM\n Chloride:\n 98 mEq/L\n 04:42 AM\n CO2:\n 20 mEq/L\n 04:42 AM\n BUN:\n 22 mg/dL\n 04:42 AM\n Creatinine:\n 0.8 mg/dL\n 04:42 AM\n Glucose:\n 105 mg/dL\n 04:42 AM\n Hematocrit:\n 27.9 %\n 04:42 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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423633, "text": "Chief Complaint: respiratory failure and encephalopathy\n 24 Hour Events:\n MRA head (-)\n MRI head showed small vessel disease, basal ganglia changes c/w\n encephalopathy, no acute ischemia\n NGT placed, lactulose initiated, tube feeds initiated\n Held off on paracentesis as per liver recs\n No neuro recs\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:52 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: 36.4\nC (97.6\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 337 mL\n PO:\n TF:\n 100 mL\n 78 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 4,095 mL\n 1,970 mL\n Urine:\n 1,295 mL\n 170 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,633 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///21/\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 104 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2147-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423635, "text": "Chief Complaint: respiratory failure and encephalopathy\n 24 Hour Events:\n MRA head (-)\n MRI head showed small vessel disease, basal ganglia changes c/w\n encephalopathy, no acute ischemia\n NGT placed, lactulose initiated, tube feeds initiated\n Held off on paracentesis as per liver recs\n No neuro recs\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:52 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: 36.4\nC (97.6\n HR: 101 (96 - 123) bpm\n BP: 139/71(91) {108/63(84) - 140/105(175)} mmHg\n RR: 11 (10 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 800 mL\n 337 mL\n PO:\n TF:\n 100 mL\n 78 mL\n IVF:\n 240 mL\n 78 mL\n Blood products:\n Total out:\n 4,095 mL\n 1,970 mL\n Urine:\n 1,295 mL\n 170 mL\n NG:\n Stool:\n 100 mL\n Drains:\n 600 mL\n 1,800 mL\n Balance:\n -3,295 mL\n -1,633 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///21/\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 104 K/uL\n 9.2 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 22 mg/dL\n 106 mEq/L\n 135 mEq/L\n 27.9 %\n 11.8 K/uL\n [image002.jpg]\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n 04:38 AM\n WBC\n 8.4\n 10.9\n 12.2\n 11.8\n Hct\n 31.0\n 28.9\n 31.6\n 27.9\n Plt\n 107\n 114\n 123\n 104\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 105\n 107\n 131\n 103\n Other labs: PT / PTT / INR:20.7/44.1/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:56/88, Alk Phos / T Bili:132/5.9,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.4 g/dL, LDH:344 IU/L, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Mr. is an 41 yo male with cirrhosis, pulm HTN, admitted for\n airway protection x 2 in setting of hepatic encephalopathy .\n .\n 1. Altered mental status. Patient intubated after an unwitness\n event of unclear etiology on floor (?worsening hepatic encephalopathy,\n large volume para, seizure). Improved with aggressive lactulose with\n good effect overnight and minimizing sedation (boluses of versed and\n fentanyl). Extubated this morning.\n - continue lactulose for >4 BMs/day and improvement of mental\n status\n - ngt placement to allow adequate lactulose intake\n - hold all further mind altering meds\n - monitor mental status\n - r/o infections\n 2. RLE weakness. Continues to have limited RLE weakness in\n spite of increased alertness. Concern for embolic event.\n - f/u MRI brain\n - f/u neck mra\n - neuro following\n 3. Airway. Intubated for airway protection, now extubated.\n 4. Cirrhosis. History of alcohol and Hep C cirrhosis with grade\n 1 varices. ON transplant list. Singnificant abdominal ascites on\n exam, though was tapped for 4 L two days ago.\n - consider para today\n - continue lactulose, lasix, spironolactone\n - continue cipro prophylaxis\n 5. Pulmonary hypertension.\n - ntinue slidenafil\n - hold iloprost for now\n 5. Anemia/thrombocytopenia: baseline hct ~27, plt 70-90..\n - guaiac stools.\n - trend Hct, platelets\n 6. Hypothyroidism. TSH was elevated 6.6->4.9, since on\n 75mcg synthroid. increased levothyroxine to 88mcg/qdaily earlier\n during admission.\n - continue synthroid\n 7. ?degenerative disk disease of cervical spine. Finding noted\n on head CT.\n - consider c-spine imaging when he improves\n clnically\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:00 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2147-10-26 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 423000, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Received Lactulose 30ml at 8pm, 2am, 4am\n Received Lactulose 60ml at 6am\n 3 bowel movements this morning\n This AM, patient is awake and alert, able to respond to questions;\n however somewhat disoriented. Oriented to place and person only;\n however was aware of running for president.\n Pt denies N/V, denies SOB or abdominal pain. Does not remember events\n which precipitated admission.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (107 - 132) bpm\n BP: 128/86(96) {112/65(79) - 143/94(99)} mmHg\n RR: 12 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 330 mL\n 860 mL\n PO:\n 800 mL\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 520 mL\n 200 mL\n Urine:\n 520 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -190 mL\n 660 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.54/29/205/23/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: MMM, no LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended with clinical\n ascites, no tenderness\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows commands, no clonus, no asterixis noted\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 23 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n WBC\n 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TCO2\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n .\n # Altered mental status: likely secondary to hepatic encephalopathy.\n Unclear etiology but probably related to Trazodone which pt took 2 of\n before event. Was given lactulose in the ED with bowel movement\n afterwards. His mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # Primary respiratory alkalosis: now resolved and patient is extubated.\n -continue supportive care\n .\n # Nausea and vomiting: Resolved. Likely gastroenteritis or could be\n from new medications for muscle spasms including magnesium which dose\n was recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # Ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # Elevated WBCs with left shift: concerning for infection although\n peritoneal fluid does not have >250 polys and does not present picture\n of SBP. Pt is afebrile and otherwise asymptomatic.\n - will continue to trend and hold off on abx at this time\n - f/u cultures from peritoneal fluid\n .\n # Anemia: HCT 29.0 today which appears to be baseline and likely from\n chronic liver disease.\n - continue to monitor, transfuse for symptoms or HCT<21.\n .\n # Thrombocytopenia: Platelets 100 this AM. Appears to be baseline and\n likely from chronic liver disease\n - continue to trend, monitor for bleeding\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of .\n Currently trending up and is 8.5 this AM. Will f/u with fractionated\n bilirubin.\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # Pulmonary hypertension: continue iloprost and sildenafil.\n .\n # Hypothyroidism: continue levothyroxine\n .\n # FEN: Regular diet with sodium restriction, on home diuretics but\n appears volume overloaded. Replete lytes PRN.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 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: 41M ESLD, pulm HTN p/w hepatic encephalopathy\n c/b respiratory failure. Extubated, stooling, paracentesis negative for\n SBP.\n Exam notable for Tm 97 BP 132/76 HR 80-100 RR 18 with sat 97 on RA.\n Icteric, frail man, NAD on RA. CTA B, RRR s1s2. Distended / tense\n ascites. No edema .Labs notable for WBC 13K, HCT 29, K+ 4.3, Cr 0.9, TB\n 8.5, INR 2.0. USG with normal portal flow per prelim report.\n Agree with plan to continue lactulose and rifaximin for decompensated\n hepatic encephalopathy. No clear precipitant except perhaps worsening\n ascites. Will f/u cultures, continue prophylaxtic antibiotics, and\n obtain formal abdominal usg with dopplers. Will need to continue\n iloprost and sildenafil for severe pulm hypertension c/w portopulmonary\n hypertension; management to be discussed with Dr. . Will\n consider therapeutic paracentesis based on d/w liver team. Remainder of\n plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:03 PM ------\n" }, { "category": "Physician ", "chartdate": "2147-10-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 422967, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Received Lactulose 30ml at 8pm, 2am, 4am\n Received Lactulose 60ml at 6am\n 3 bowel movements this morning\n This AM, patient is awake and alert, able to respond to questions;\n however somewhat disoriented. Oriented to place and person only;\n however was aware of running for president.\n Pt denies N/V, denies SOB or abdominal pain. Does not remember events\n which precipitated admission.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (107 - 132) bpm\n BP: 128/86(96) {112/65(79) - 143/94(99)} mmHg\n RR: 12 (12 - 27) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 330 mL\n 860 mL\n PO:\n 800 mL\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 520 mL\n 200 mL\n Urine:\n 520 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -190 mL\n 660 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.54/29/205/23/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: MMM, no LAD\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended with clinical\n ascites, no tenderness\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows commands, no clonus, no asterixis noted\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 23 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n WBC\n 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TCO2\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n .\n # Altered mental status: likely secondary to hepatic encephalopathy.\n Unclear etiology but probably related to Trazodone which pt took 2 of\n before event. Was given lactulose in the ED with bowel movement\n afterwards. His mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # Primary respiratory alkalosis: now resolved and patient is extubated.\n -continue supportive care\n .\n # Nausea and vomiting: Resolved. Likely gastroenteritis or could be\n from new medications for muscle spasms including magnesium which dose\n was recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # Ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # Elevated WBCs with left shift: concerning for infection although\n peritoneal fluid does not have >250 polys and does not present picture\n of SBP. Pt is afebrile and otherwise asymptomatic.\n - will continue to trend and hold off on abx at this time\n - f/u cultures from peritoneal fluid\n .\n # Anemia: HCT 29.0 today which appears to be baseline and likely from\n chronic liver disease.\n - continue to monitor, transfuse for symptoms or HCT<21.\n .\n # Thrombocytopenia: Platelets 100 this AM. Appears to be baseline and\n likely from chronic liver disease\n - continue to trend, monitor for bleeding\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of .\n Currently trending up and is 8.5 this AM. Will f/u with fractionated\n bilirubin.\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # Pulmonary hypertension: continue iloprost and sildenafil.\n .\n # Hypothyroidism: continue levothyroxine\n .\n # FEN: Regular diet with sodium restriction, on home diuretics but\n appears volume overloaded. Replete lytes PRN.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 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": "2147-10-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 422985, "text": "41M with PMH of pulmonary hypertension, ESLD from alcohol and hepatitis\n C on transplant list, hypothyroidism who presents with altered mental\n status. The day prior to presentation, the patient was complaining of\n feeling sick and nauseated. He vomited several times but did take all\n of his medications per his mother as she gives them to him. She went to\n check on him the morning of presentation and he was unresponsive and\n gagging on emesis. She called EMS. At the OSH, he was intubated for\n airway protection. CXR was negative for infiltrate, U/A was clean and\n CT of the head was negative for an acute process.\n Hepatic encephalopathy\n Assessment:\n Pt oriented x 2 (person and place). At times confused about when he\n will go home. Anxious about relatives.\n Action:\n Continues on PO lactulose TID, reoriented as needed to current\n situation, family members in to visit this afternoon.\n Response:\n Mental status improving on lactulose, pt less disoriented, pt less\n anxious now that family in to visit.\n Plan:\n Continue lactulose, continue to re-orient, family likely to stay until\n transferred to 10.\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 422992, "text": "41M with PMH of pulmonary hypertension, ESLD from alcohol and hepatitis\n C on transplant list, hypothyroidism who presents with altered mental\n status. The day prior to presentation, the patient was complaining of\n feeling sick and nauseated. He vomited several times but did take all\n of his medications per his mother as she gives them to him. She went to\n check on him the morning of presentation and he was unresponsive and\n gagging on emesis. She called EMS. At the OSH, he was intubated for\n airway protection. CXR was negative for infiltrate, U/A was clean and\n CT of the head was negative for an acute process.\n Hepatic encephalopathy\n Assessment:\n Pt oriented x 2 (person and place). At times confused about when he\n will go home. Anxious about relatives.\n Action:\n Continues on PO lactulose TID, reoriented as needed to current\n situation, family members in to visit this afternoon.\n Response:\n Mental status improving on lactulose, pt less disoriented, pt less\n anxious now that family in to visit.\n Plan:\n Continue lactulose, continue to re-orient, family likely to stay until\n transferred to 10.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 78.6 kg\n Daily weight:\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; ostroporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:87\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 112 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,150 mL\n 24h total out:\n 1,030 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 04:11 AM\n Potassium:\n 4.3 mEq/L\n 04:11 AM\n Chloride:\n 101 mEq/L\n 04:11 AM\n CO2:\n 23 mEq/L\n 04:11 AM\n BUN:\n 23 mg/dL\n 04:11 AM\n Creatinine:\n 0.9 mg/dL\n 04:11 AM\n Glucose:\n 106 mg/dL\n 04:11 AM\n Hematocrit:\n 29.0 %\n 04:11 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n PIV x 2\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: none\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 10\n Date & time of Transfer: 14:30\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425047, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n * extubated after MS improved\n * hyponatremic to Na 120 -> restricted PO fluids and re-checked labs\n -> Na 122\n * patient stable overnight\n * still to do: auto cpap v sleep study, consider re-image head\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:42 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: 36.7\nC (98\n HR: 112 (79 - 112) bpm\n BP: 116/67(78) {86/40(51) - 138/82(95)} mmHg\n RR: 16 (9 - 22) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 270 mL\n PO:\n 270 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 135 mL\n Urine:\n 730 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n 131 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Recurrent altered mental status: DDX includes infection (less likely\n given this is the third episode in the last few weeks and work up for\n infection has been negative, currently leukocytosis or fevers), stroke\n or head bleed (unlikely for similar reason and prior CT x2 and MRI\n brain all negative), encephalopathy (likely), hyponatremia (could be\n contributing given sodium of 120 is lower than he has been given he\n restarted diuretics yesterday), sleep disorder (given all episodes\n occur first thing in the AM).\n -for hepatic encephalopathy- dose lactulose q2hrs until bowel movements\n then back down with goal bowel movements 5-6 per day, continue\n rifaximine\n -for hyponatremia- repeat labs in 4 hrs. If still hyponatremic, will\n need repletion. Hold diuretics.\n -sleep disorder- continuous oxygen monitoring, ABG when awake and\n extubated for baseline. sleep study needed but may not be able to do in\n house on the weekend. Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # alkylosis: Would think with altered mental status, that his CO2 would\n be high causing an acidosis not alkylosis with low CO2. Could imply a\n sleep disturbance as cause. See above.\n -monitor ABG\n -currently changing to PS ventilation and will resend ABG in 30 mins.\n -ween vent as tolerated.\n -has been extubated quickly on prior episodes.\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil. not be able to get iloprost\n while on vent. Will discuss with respiratory and pharmacy.\n # Hypothyroidism: continue levothyroxine\n # FEN: NPO for now. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 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": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425042, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended w/ acities. Pt c/o of increasing abd discomfort,\n pressure and cramping. Receiving lactulose, no Bm at this time. Pt\n tossing and turning in bed\n Action:\n Pt turned and repositioned for comfort. Dr. in to evaluate pt. KUB\n ordered. Oxycodone for discomfort.\n Response:\n Minimal reflief from oxycodone\n Plan:\n KUB done, hold Lactulose at this time. Possible paracenthesis today.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat Na+ 122, restricting H20, pt c/o feeling thirsty.\n Action:\n Maintain fluid restriction. Taking juice judiciously. Repeat lytes in\n am.\n Response:\n Plan:\n Continue fluid /water restriction, follow electrolytes.\n" }, { "category": "Nursing", "chartdate": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425043, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen distended w/ acities. Pt c/o of increasing abd discomfort,\n pressure and cramping. Receiving lactulose, no Bm at this time. Pt\n tossing and turning in bed\n Action:\n Pt turned and repositioned for comfort. Dr. in to evaluate pt. KUB\n ordered. Oxycodone for discomfort.\n Response:\n Minimal reflief from oxycodone\n Plan:\n KUB done. Hold Lactulose at this time. Possible paracenthesis today.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat Na+ 122, restricting H20, pt c/o feeling thirsty.\n Action:\n Maintain fluid restriction. Taking juice judiciously. Repeat lytes in\n am.\n Response:\n Am Na+ 125.\n Plan:\n Continue fluid /water restriction, follow electrolytes.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425210, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Abdominal pain (including abdominal tenderness)\n Assessment:\n No further abd discomfort . abd less distended. amt of acites\n present. Up to commode for 800cc of liq stool\n Action:\n Evening dose of lacutose held. MDs aware.\n Response:\n Additional bm very small.\n Plan:\n Continue lacturlose in am. Evaluate pt for paracenthesis.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pm labs w/ Na+122, K+3.6, slt metabolic acidosis.\n Action:\n Potassium replaced. Pt on 1500cc fluid restriction. Clr liq diet D/C\n restarted on solids.\n Response:\n Plan:\n Continue 1500cc fluid restriction.\n Hepatic encephalopathy\n Assessment:\n Alert and oriented. Tired and feeling sleepy due to not sleeping Sat\n pm.\n Action:\n Continue lactulose in am.\n Response:\n Last 24hrs w/ 3300ccof liq stool.\n Plan:\n monitor for any mental status changes.\n" }, { "category": "Respiratory ", "chartdate": "2147-11-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 426060, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Tracheostomy planned\n Bedside Procedures:\n Comments: Patient remains on CPAP/PSV 5/5, 40%, producing large VT. No\n morning abg results.\n RSBI = 13 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425206, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had bileus liq\n stool +undigested food. CT Scan neg. pt back on clr liq.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, soft. Pt w/o further Abd pain\n since multiple stools. Some discomfort from acities.\n Action:\n Response:\n Plan:\n Discuss and evaluate for paracenthesis\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow\n Response:\n Plan:\n Continue meds as ordered and assess response.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored\n Response:\n Pt used inhaler x 2 with set up from Resp/RN and assistance from\n brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction, especially water\n Response:\n Plan:\n Follow lytes and treat as needed per MICU team.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy,\n Action:\n Response:\n Plan:\n Lactulose as ordered\n" }, { "category": "Physician ", "chartdate": "2147-11-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425209, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - CT: no SBO, + ascites\n - hepatology - do not tap unless painful\n - abd px disappeared after 1800 cc stool output\n - levothyroxin & cipro changed back to PO\n - Iloprost started\n - Needs sleep study\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 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 06:18 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: 103 (85 - 113) bpm\n BP: 101/49(61) {88/37(50) - 136/72(84)} mmHg\n RR: 14 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 2,590 mL\n 240 mL\n PO:\n 1,990 mL\n 240 mL\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 3,670 mL\n 180 mL\n Urine:\n 1,070 mL\n 180 mL\n NG:\n Stool:\n 2,600 mL\n Drains:\n Balance:\n -1,080 mL\n 60 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 98 mEq/L\n 122 mEq/L\n 27.9 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: KUB with air fluid levels concerning for SBO and\n patient had no stools x 24 hours. Made NPO including meds & CT scan to\n check for SBO. After drinking contrast patient had large volume stool\n output. CT scan preliminarily no SBO, but ascities present. Abdominal\n pain now resolved after BMs. Will advance diet to clears then as\n tolerated.\n # Recurrent altered mental status: Mental status currently improved.\n DDX includes infection (less likely given this is the third episode in\n the last few weeks and work up for infection has been negative,\n currently no leukocytosis or fevers), stroke or head bleed (unlikely\n for similar reason and prior CT x2 and MRI brain all negative),\n encephalopathy (likely), hyponatremia (could be contributing given\n sodium of 120 is lower than he has been given he restarted diuretics\n yesterday), sleep disorder (given all episodes occur first thing in the\n AM).\n -for hepatic encephalopathy- dose lactulose q2hrs until bowel movements\n then back down with goal bowel movements 5-6 per day, continue\n rifaximine\n -for hyponatremia- improving, hold diuretics, check pm lytes\n -sleep disorder- continuous oxygen monitoring, ABG when awake and\n extubated for baseline. sleep study needed but may not be able to do in\n house on the weekend. Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # alkylosis: Would think with altered mental status, that his CO2 would\n be high causing an acidosis not alkylosis with low CO2. Could imply a\n sleep disturbance as cause. See above.\n -monitor ABG\n -currently changing to PS ventilation and will resend ABG in 30 mins.\n -ween vent as tolerated.\n -has been extubated quickly on prior episodes.\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Clears advance to full liquids for now. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:29 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": "2147-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425921, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs, intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high 90\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for white thin frothy copious to moderate\n secretion. MD notified. ABG repeated X3. Around 1500 hrs, patient is\n more awake & gasping. ABG repeated. IVF started @ 125 ml/hr for 1000\n ml.\n Response:\n F/U serial ABG.\n Plan:\n Continue monitoring his resp status & F/U with ABG\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 126, urine is dark amber 20-30 ml/hr.\n Action:\n IVF (0.9% NS) started @ 125 ml/hr for 1000 ml. Holding Lasix for now.\n Response:\n No immediate response.\n Plan:\n Next lytes at 1900 hrs. Follow sodium loosely.\n" }, { "category": "Nursing", "chartdate": "2147-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425925, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs, intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n Altered mental status\n Assessment:\n Patient unresponsive since morning, around 1500 hrs, patient more\n awake , gasping, copious secretion, moving in bed but does not follow\n any commands . Pupils are 6 mm dilated, sluggish . MD notified.\n Action:\n Will cont monitoring his mental status. No sedation to be given.\n Response:\n More awake towards evening.\n Plan:\n Will cont monitoring mental status closely.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high 90\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for white thin frothy copious to moderate\n secretion. MD notified. ABG repeated X3. Around 1500 hrs, patient is\n more awake & gasping. ABG repeated. IVF started @ 125 ml/hr for 1000\n ml.\n Response:\n F/U serial ABG.\n Plan:\n Continue monitoring his resp status & F/U with ABG\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 126, urine is dark amber 20-30 ml/hr.\n Action:\n IVF (0.9% NS) started @ 125 ml/hr for 1000 ml. Holding Lasix for now.\n Response:\n No immediate response.\n Plan:\n Next lytes at 1900 hrs. Follow sodium loosely.\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 425928, "text": "Chief Complaint: Altered Mental status\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 41 year old male who is well known to MICU green service with hx of\n cirrhossis Hep C and EtOH with mulipte admissions to the ICU in the\n setting of altered mental status now admitted after being found with\n diminished responsiveness on the floor this morning. He was not noted\n to have any seizure activity, he was not hypercarbic on ABG. He was\n intubated for an inability to defend his airway. There was a question\n of a nose bleed for which an NG tube was placed which did not reveal\n blood in the stomach\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies\n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a mean\n pressure of 8. Notably he had a pulmonary capillary wedge pressure of\n approximately 15 at that time and his cardiac output was normal with\n 6.7 liters per minute, cardiac index of 3.7. His pulmonary vascular\n resistance was nearly normal at 251 and he was in sinus rhyth at that\n time with a heart rate of 90\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n ? Sleep disordered breathing: had sleep study which was non diagnostics\n Occupation: lives with mom\n Drugs: remote IVD\n Tobacco: quit \n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 90) bpm\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n RR: 19 (14 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: icteric\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended and fluid\n filled by exam in the lower quads.\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: no clonus. + gag, corneal, pupils. No increased DTR\n / Radiology\n 123 K/uL\n 30\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 07:19 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other : PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: ET in good position, NG ion good position. No infiltrate\n or effusion, improved volumes when compared to prior film\n Assessment and Plan\n 41 yo male with hx of HepC /EtOH cirrhosis admitted with altered mental\n status and inability to defend airway. This is consistent with prior\n admissions to the ICU in the setting of decompensated encephalopathy,\n notably these events tedn to be noticed in the early morning hours.\n Recently he had a sleep study which although not diagnostic in\n quality(he did not achieve REM sleep) seemed to suggest that there was\n an element of sleep disordered breathing.\n HEPATIC ENCEPHALOPATHY / Altered mental status: this is the third\n admission to the ICU this month for altered MS \n picture. Concerning findings on this admission include a suggestion of\n gaze deviation. I am concerned for both a head bleed (given his\n coagulopathy) and sub-clinical status however this is similar to his\n previous admission both in exam and timing of the event. For now it\n seems reasonable to trial him on lactulose and see if we can get\n improvement. If there is no improvement in his exam we can investigate\n via head CT and/or EEG. He likely has some element of sleep disordered\n breathing and I think he would benefit from CPAP at night. Additional\n components include metabolic (hyponatremia). There does not appear to\n be an infectious component. For now we will cont PS ventilation until\n his MS improves.\n - Defer head CT and EEG for now\n - regimen as below for encephalopathy\n - SBP prophylaxis with cipro\n > Respiratory alkaosis: we have seen this in his past admission and it\n was thought to be both ascites, liver dysfunction and potentially\n exacerbated by central causes. We will cont to follow for now.\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY): chronic and related to his\n liver failure and diuresis. Will defer additional diuresis and follow\n Na closely\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: would cont previous regimen of\n lactulose, rifaximin and flagyl. There was a question of a nose bleed\n that did not appear related to a GI bleed (hct stable, neg OG return),\n will d/w liver.\n > Pulmonary hypertension: holding treatment for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Defer tube feeds for now\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:47 AM\n Comments:\n Prophylaxis:\n DVT: Boots, holding hep sq in the setting of\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 Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426388, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:00 AM\n - Extubated successfully.\n - Ongoing discussion re: trach, may get next week. Nighttime PPV until\n then.\n - CPAP overnight, tolerated well\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 02:11 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 08:04 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: 92 (92 - 119) bpm\n BP: 121/62(74) {99/51(65) - 151/96(100)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 2,120 mL\n 90 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,150 mL\n Blood products:\n Total out:\n 1,264 mL\n 330 mL\n Urine:\n 964 mL\n 330 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 856 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 936) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///16/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 16 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 107 mEq/L\n 130 mEq/L\n 25.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n 10.0\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n Plt\n 123\n 92\n 86\n 86\n 77\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n TCO2\n 20\n 18\n 17\n Glucose\n 105\n 107\n 113\n 129\n 103\n 110\n 99\n Other labs: PT / PTT / INR:24.4/49.5/2.4, ALT / AST:59/102, Alk Phos /\n T Bili:126/7.1, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:349 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence and respiratory failure. Again prompting respiratory code\n and intubation for airway protection on floor. Differential has\n included hepatic encephalopathy (worsening overnight with no overnight\n doses of lactulose), OSA or other sleep disordered breathing. Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours).\n - Treat aggressively for hepatic encephalopathy - now\n lactulose TID to maintain 4+ BM/day, continue rifaximin and flagyl.\n need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation.\n - Extubation likely today.\n - Discussion yesterday re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea. Would also be\n beneficial if central apnea in that could easily be hooked up to vent\n (but ?need to go to vent facility following discharge) as opposed to\n repeated intubations and potential hypoxic exposures. Will discuss\n with liver team and Dr. .\n .\n # Respiratory alkalosis/metabolic acidosis. Respiratory drive likely\n related to ascites/large abdomen with other hormonal effects from\n cirrhosis. Also with metabolic acidosis\n may be in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings (), plan\n extubate today.\n - Recheck urinary anion gap (was dry yesterday during check)\n .\n # Hyponatremia: Improving.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now as still appears dry.\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now.\n .\n # Leukocytosis. To 18K yesterday, now trending down. ?stress response\n from intubation/resp failure.\n - f/u c.diff\n - trend fever curve; defer para given lack of abd pain\n currently.\n .\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - can restart HSQ.\n .\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition:\n Comments: regular, will change to low Na\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:10 AM\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:ICU\n" }, { "category": "Physician ", "chartdate": "2147-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426389, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:00 AM\n - Extubated successfully.\n - Ongoing discussion re: trach, may get next week. Nighttime PPV until\n then.\n - CPAP overnight, tolerated well\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 02:11 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 08:04 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: 92 (92 - 119) bpm\n BP: 121/62(74) {99/51(65) - 151/96(100)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 2,120 mL\n 90 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,150 mL\n Blood products:\n Total out:\n 1,264 mL\n 330 mL\n Urine:\n 964 mL\n 330 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 856 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 936) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///16/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 16 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 107 mEq/L\n 130 mEq/L\n 25.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n 10.0\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n Plt\n 123\n 92\n 86\n 86\n 77\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n TCO2\n 20\n 18\n 17\n Glucose\n 105\n 107\n 113\n 129\n 103\n 110\n 99\n Other labs: PT / PTT / INR:24.4/49.5/2.4, ALT / AST:59/102, Alk Phos /\n T Bili:126/7.1, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:349 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence and respiratory failure. Again prompting respiratory code\n and intubation for airway protection on floor. Differential has\n included hepatic encephalopathy (worsening overnight with no overnight\n doses of lactulose), OSA or other sleep disordered breathing. Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours).\n - Treat aggressively for hepatic encephalopathy - now\n lactulose TID to maintain 4+ BM/day, continue rifaximin and flagyl.\n need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation.\n - Extubation likely today.\n - Discussion continues re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea. Would also be\n beneficial if central apnea in that could easily be hooked up to vent\n (but ?need to go to vent facility following discharge) as opposed to\n repeated intubations and potential hypoxic exposures. Will discuss\n with liver team and Dr. .\n .\n # Respiratory alkalosis/metabolic acidosis. Respiratory drive likely\n related to ascites/large abdomen with other hormonal effects from\n cirrhosis. Also with metabolic acidosis\n may be in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n .\n # Hyponatremia: Improving.\n - 1 L fluid restriction\n - Hold diuretics\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now as still appears dry.\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now.\n .\n # Leukocytosis. To 18K post event, now trending down. ?stress response\n from intubation/resp failure. C.diff neg. This AM with GPCs in\n ascites fluid from tap , 70 WBCs with 7% PMNs. ?contaminant.\n - trend fever curve; consider repeat para.\n - f/u culture/ID/MIC; ?start vanco\n .\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition:\n Comments: regular, will change to low Na\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:10 AM\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:ICU\n" }, { "category": "Nursing", "chartdate": "2147-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425987, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n Altered mental status\n Assessment:\n Patient unresponsive since morning, around 1500 hrs, patient more\n awake , moving all extremities but does not follow any commands.\n ,gasping, copious secretion.. Pupils are mm dilated, yellowish,\n sluggishly reactive to light. . MD notified.\n Action:\n Will cont monitoring his mental status. No sedation to be given.\n Response:\n More awake towards evening but not following any commands\n Plan:\n Will cont monitoring mental status closely.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high 90\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for white thin frothy copious to moderate\n secretion. MD notified. ABG repeated X3. Around 1500 hrs, patient is\n more awake & gasping. ABG repeated. IVF started @ 125 ml/hr for 1000\n ml.\n Response:\n F/U serial ABG. Last ABG : 7.49/22/69/17. RR 12-18 bpm.\n Plan:\n Continue monitoring his resp status & F/U with ABG\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 126, urine is dark amber 20-30 ml/hr.\n Action:\n IVF (0.9% NS) started @ 125 ml/hr for 1000 ml. Holding Lasix for now.\n Urine electrolyte sent.\n Response:\n No immediate response.\n Plan:\n Next lytes at 1900 hrs. Follow sodium closely.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n Awaiting.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity.\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426112, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n - continued lactulose\n - UA with hyaline casts and blood\n - mental status with slow improvement, 130am responsive to commands in\n all exts, appropriate eye contact\n - urine lytes 0%, FeUrea 13.2%, urine osm 508, hr 105 --> IVF NS\n - ABG pm - 7.49/22/169\n - lactate trend downward from 3.7 to 2 at 9pm, then back to 3.7 in am\n - needed to start propofol gtt at 5am due to discomfort and concern for\n pulling NGT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 406 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 236 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 137 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\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: (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 Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 86 K/uL\n 8.7 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n KNOWLEDGE DEFICIT\n ICU Care\n Nutrition:\n Comments: NPO for planned extubation\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\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": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426113, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n - continued lactulose\n - UA with hyaline casts and blood\n - mental status with slow improvement, 130am responsive to commands in\n all exts, appropriate eye contact\n - urine lytes 0%, FeUrea 13.2%, urine osm 508, hr 105 --> IVF NS\n - ABG pm - 7.49/22/169\n - lactate trend downward from 3.7 to 2 at 9pm, then back to 3.7 in am\n - needed to start propofol gtt at 5am due to discomfort and concern for\n pulling NGT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 406 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 236 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 137 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\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: (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 Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 86 K/uL\n 8.7 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition:\n Comments: NPO for planned extubation\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\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": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426114, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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 07:44 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: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 392 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 222 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 123 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: upper airway)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time\n Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had\n Liver failure: follwoed by liver service, on lactulose, rifax and flagy\n for clearance\n - cont above regimen\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426116, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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 07:44 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: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 392 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 222 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 123 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: upper airway)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time\n Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had\n Liver failure: follwoed by liver service, on lactulose, rifax and flagy\n for clearance\n - cont above regimen\n Hyponatremia:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426155, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n - continued lactulose\n - UA with hyaline casts and blood\n - mental status with slow improvement, 130am responsive to commands in\n all exts, appropriate eye contact\n - urine lytes 0%, FeUrea 13.2%, urine osm 508, hr 105 --> IVF NS\n - ABG pm - 7.49/22/169\n - lactate trend downward from 3.7 to 2 at 9pm, then back to 3.7 in am\n - needed to start propofol gtt at 5am due to discomfort and concern for\n pulling NGT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 406 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 236 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 137 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\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: (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 Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended.\n Unchanged umbilical hernia, reducible. Nontender belly.\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands in all extremities,\n Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not\n assessed. Appropriate and interactive.\n Labs / Radiology\n 86 K/uL\n 8.7 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence and respiratory failure. Again prompting respiratory code\n and intubation for airway protection on floor. Differential has\n included hepatic encephalopathy (worsening overnight with no overnight\n doses of lactulose), OSA or other sleep disordered breathing. Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours).\n - Treat aggressively for hepatic encephalopathy - now\n lactulose TID to maintain 4+ BM/day, continue rifaximin and flagyl.\n need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation.\n - Extubation likely today.\n - Discussion yesterday re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea. Would also be\n beneficial if central apnea in that could easily be hooked up to vent\n (but ?need to go to vent facility following discharge) as opposed to\n repeated intubations and potential hypoxic exposures. Will discuss\n with liver team and Dr. .\n # Respiratory alkalosis/metabolic acidosis. Respiratory drive likely\n related to ascites/large abdomen with other hormonal effects from\n cirrhosis. Also with metabolic acidosis\n may be in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings (), plan\n extubate today.\n - Recheck urinary anion gap (was dry yesterday during check)\n # Hyponatremia: Improving.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now as still appears dry.\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now.\n # Leukocytosis. To 18K yesterday, now trending down. ?stress response\n from intubation/resp failure.\n - f/u c.diff\n - trend fever curve; defer para given lack of abd pain\n currently.\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - can restart HSQ.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition:\n Comments: NPO for planned extubation\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots, can add HSQ\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": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426242, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 10:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 04:20 PM\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: 119 (93 - 126) bpm\n BP: 151/76(89) {100/45(57) - 151/76(89)} mmHg\n RR: 12 (11 - 20) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,589 mL\n 1,761 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,269 mL\n 1,181 mL\n Blood products:\n Total out:\n 470 mL\n 704 mL\n Urine:\n 470 mL\n 704 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 1,057 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 1,239) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///15/\n Ve: 14.6 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 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 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": "2147-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426120, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n - continued lactulose\n - UA with hyaline casts and blood\n - mental status with slow improvement, 130am responsive to commands in\n all exts, appropriate eye contact\n - urine lytes 0%, FeUrea 13.2%, urine osm 508, hr 105 --> IVF NS\n - ABG pm - 7.49/22/169\n - lactate trend downward from 3.7 to 2 at 9pm, then back to 3.7 in am\n - needed to start propofol gtt at 5am due to discomfort and concern for\n pulling NGT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 406 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 236 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 137 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\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: (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 Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 86 K/uL\n 8.7 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing. Most likely\n explanation is severe hepatic encephalopathy with overnight break from\n lactulose, as these episodes have all occurred within a few hours of\n 8am meds (no lactulose for at least 8-10 hours).\n - Treat aggressively for hepatic encephalopathy - now\n lactulose Q4-6H to start until mental status clearing, continue\n rifaximin and flagyl. need specific overnight wakeup for\n lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Extubation today\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition:\n Comments: NPO for planned extubation\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\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": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426143, "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 >improved MS over last 12hr\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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 07:44 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: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 392 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 222 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 123 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: upper airway)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n CXR : ET in good position, no infil or effusion.\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n ICU Care\n Nutrition:\n NPO f\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426145, "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 >improved MS over last 12hr\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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 07:44 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: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 392 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 222 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 123 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: upper airway)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n CXR : ET in good position, no infil or effusion.\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n NPO f\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426367, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Assessment:\n Received Pt. on room air satting at high >95\ns Pt. successfully\n extubated yesterday at 1100 hrs. Was placed on CPAP at 2300 last\n evening and tolerated this well.\n Action:\n Pt. placed on CPAP at 2300 and tolerated this well. Pt. d/c\nd this\n treatment at 0630 this am.\n Response:\n Satting at high 90\ns on room air. Denied SOB.\n Plan:\n Continue monitoring his resp status. Will place on CPAP at night . If\n pt. fails CPAP trial over the weekend. Pt. will be trached on Monday.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen firm distended, ascittis. hepatic encephalopathy, LFT\n elevated. & coagulopathic. H/O epistaxis.\n Action:\n lactulose 60 mlTID ( scheduled Up to BSC X2.\n Response:\n Moderate amt\ns of Loose stool X2. Sitting Up at chair.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care w/\n barrier cream.\n Respiratory Alkalosis.\n Assessment:\n Pt. weaned to room air yesterday following extubation. Presently\n satting at high >95\n Action:\n Pt. exhibits productive cough for thick yellow tinged sputum. patient\n is awake and appropriate. Pt. placed on CPAP.\n Response:\n Pt. tolerated CPAP with no change n\\in mental status noted.\n Plan:\n Continue monitoring his resp status & Possible trach procedure on\n Monday if pt. does not tolerate CPAP trial..\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened. Bruises at rt upper chhek from Adhesive tape.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n No change at this time.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity. Sitting\n up at chair.\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426465, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Denies abdominal pain,abd firm distended + bowel sounds.\n Action:\n Monitored.\n Response:\n Denies abd pain.\n Plan:\n Monitor abd pain.\n Knowledge Deficit\n Assessment:\n Oriented x 3, pleasant. asks questions. Often states you should ask my\n mother she would know. anxious at times,\n Action:\n Questions answered, reassuarance offered.\n Response:\n Calms with reassurance\n Plan:\n Offer reassurance , encourage verbalization.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Regular diet to be changed to low na. continue 1 l fluid restriction.\n Lasix restarted. Ho notified of uo<30\n Response:\n Following fluid restriction. Litlle effect from lasix. No treatment for\n decreased uo md .\n Plan:\n Monitor na and intake. Monitor diuresis i+0.\n Hepatic encephalopathy\n Assessment:\n Alert,\n Action:\n Monitor , lactulose given\n Response:\n 1 medium loose stool\n Plan:\n Monitor mental status, bowel movements, continue Lactulose,\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Documented pulm htn\n Action:\n Meds reordered, however lioprost unavailable until Tuesday .families\n supply is out and pt pharmacy will not dispense until pt out of\n hospital. Mds aware.\n Response:\n Stable at present\n Plan:\n Administer meds when available, monitor vs. md to order Viagra.\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats\n Response:\n O2 sat 93%\n Plan:\n Monitor respiratory status, 02 sats, niv mask ventilation at night as\n per orders.\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426441, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Denies abdominal pain,abd firm distended + bowel sounds\n Action:\n Monitored\n Response:\n Plan:\n Monitor abd pain\n Knowledge Deficit\n Assessment:\n Oriented x 3, pleasant. asks questions. Often states you should ask my\n mother she would know. anxious at times\n Action:\n Questions answered, reassuarance offered.\n Response:\n Calms with reassurance\n Plan:\n Offer reassurance , encourage verbalization.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Regular diet to be changed to low na. continue 1 l fluid restriction.\n Lasix restarted\n Response:\n Following fluid restriction\n Plan:\n Monitor na and intake. Monitor diuresis i+0.\n Hepatic encephalopathy\n Assessment:\n Alert,\n Action:\n Monitor , lactulose given\n Response:\n 1 medium loose stool\n Plan:\n Monitor mental status, bowel movements, continue Lactulose,\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Documented pulm htn\n Action:\n Meds reordered, however lioprost unavailable until Tuesday .families\n suppy is out and pt pharmacy will not dispense until pt out of\n hospital. Mds aware.\n Response:\n Stable at present\n Plan:\n Administer meds when available, monitor vs.\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats\n Response:\n O2 sat 93%\n Plan:\n Monitor respiratory status, 02 sats, niv mask ventilation at night as\n per orders.\n" }, { "category": "Physician ", "chartdate": "2147-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426442, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:00 AM\n - Extubated successfully.\n - Ongoing discussion re: trach, may get next week. Nighttime PPV until\n then.\n - CPAP overnight, tolerated well\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 02:11 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 08:04 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: 92 (92 - 119) bpm\n BP: 121/62(74) {99/51(65) - 151/96(100)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 2,120 mL\n 90 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,150 mL\n Blood products:\n Total out:\n 1,264 mL\n 330 mL\n Urine:\n 964 mL\n 330 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 856 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 936) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///16/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: No acute distress, sitting up in chair.\n Eyes / Conjunctiva: PERRL, icteric sclera.\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal) SM at LSB.\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: (Breath Sounds: Clear : ), diminished at bases.\n Abdominal: Soft, Non-tender, Distended (unchanged)\n Extremities: Right: 1+, Left: 1+ edema\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): place, month, year , appropriate, slightly\n slowed speech (unchanged)\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 16 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 107 mEq/L\n 130 mEq/L\n 25.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n 10.0\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n Plt\n 123\n 92\n 86\n 86\n 77\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n TCO2\n 20\n 18\n 17\n Glucose\n 105\n 107\n 113\n 129\n 103\n 110\n 99\n Other labs: PT / PTT / INR:24.4/49.5/2.4, ALT / AST:59/102, Alk Phos /\n T Bili:126/7.1, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:349 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x 4 on floor. Differential has included\n hepatic encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing. episodes have all\n occurred within a few hours of 8am meds (no lactulose for at least \n hours).\n - lactulose TID to maintain 4+ BM/day, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n continue nighttime CPAP (tolerating well thus\n far).\n - Discussion continues re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea (though unclear\n if this is the cause). Would also be beneficial if central apnea in\n that could easily be hooked up to vent (but weighing risks, ?need to go\n to vent facility following discharge, increased risk of\n infections/VAPs) as opposed to repeated intubations and potential\n hypoxic exposures. Will continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold sildenifil; restart iloprost..\n ICU Care\n Nutrition:\n Comments: regular, will change to low Na\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:10 AM\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:ICU\n ------ Protected Section ------\n Critical Care\n Present for key portions of history and physical exam. Agree with Dr.\n \ns assessment and plan. Repeated intubations for obtundation\n without structural lesions. Presumably events reflecting a combination\n of hepatic encephalopathy and OSA, as well as hyponatremia. No\n evidence of acute intrinsic lung disease and sleep apnea is only mild.\n Strongly doubt a trache would be of help and would be very reluctant to\n intubate in the future for\nairway protection\n. Agree with need for\n aggressive management of metabolic causes of altered MS.\n Time spent 35 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 15:29 ------\n" }, { "category": "Physician ", "chartdate": "2147-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426599, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Peritoneal fluid with GPCs --> coag negative staph, likely contaminant\n Unable to get iloprost.\n Viagra resumed\n Diuretics resumed\n On CPAP overnight\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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 08:06 AM\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: 35.6\nC (96\n HR: 93 (78 - 116) bpm\n BP: 111/56(69) {90/54(61) - 126/82(89)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,100 mL\n 270 mL\n PO:\n 1,010 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,025 mL\n 255 mL\n Urine:\n 1,025 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\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 91 K/uL\n 8.8 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo M with pulmonary hypertension, ESLD on transplant list with Hep C\n cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with his\n fourth episode of altered mental status requiring intubation for airway\n protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x 4 on floor. Differential has included\n hepatic encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing. episodes have all\n occurred within a few hours of 8am meds (no lactulose for at least \n hours).\n - lactulose TID to maintain 4+ BM/day, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n continue nighttime CPAP (tolerating well thus\n far).\n - Discussion continues re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea (though unclear\n if this is the cause). Would also be beneficial if central apnea in\n that could easily be hooked up to vent (but weighing risks, ?need to go\n to vent facility following discharge, increased risk of\n infections/VAPs) as opposed to repeated intubations and potential\n hypoxic exposures. Will continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold sildenifil; restart iloprost..\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426514, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management; pt will stay in\n MICU 7 for bs, auto-set at HS for ? OSA, ongoing discussion of possible\n trach d/t apneic episodes\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Low Na+ diet, continue 1 l fluid restriction, Lasix restarted, U/O\n overnight 50-25 cc/hr\n Response:\n Following fluid restriction. Little effect from lasix. No treatment for\n decreased U/O\n Plan:\n Monitor Na+ and intake. Monitor diuresis, I+O\n Hepatic encephalopathy\n Assessment:\n A+Ox3, not confused\n Action:\n Monitor MS, continues lactulose regimen\n Response:\n Multiple loose brown stools overnight\n Plan:\n Monitor mental status, bowel movements, continue Lactulose,\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with pulmonary HTn, on flolan IH at home\n Action:\n Meds reordered, however lioprost unavailable until Tuesday, family\n supply is out and pt pharmacy will not dispense to pt as inpatient; MDs\n aware.\n Response:\n Stable at present\n Plan:\n Administer meds when available, restarted viagra\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats; auto-set at HS\n Response:\n O2 sat 93%, tolerating CPAP\n Plan:\n Monitor respiratory status, 02 sats, continue auto-set\n" }, { "category": "Physician ", "chartdate": "2147-11-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 424918, "text": "Chief Complaint: respiratory arrest, altered mental status\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 41 yr old man with pHTN ESLD (etoh and hep c) presented initially on\n . On he was in MICU for - intubated, head CT neg, Rx with\n lactulose and cleared and extubated. Negative diagnosic paracentecis\n was negative. Called out to 10. 24 after called out was found\n unresponsive again. Intuabted on floor brought to MICU Green. Chest CT\n neg for PNA or asp. Neuro consult- head CT and MRI- mild abnormality in\n hypothalamuc. 24 hrs in ICU and called back out again. Had done well on\n the floor since then but issues have been management of fluids.\n Restarted aldactone. This am was found unresponsive. ABG: 7.52/24/74 -\n but was intubated for airway protection. Hemodynamics stable. Tx to\n MICU for further management.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 Hep C\n ETOH cirrhosis\n Hypothyroid\n Grade 1 eso varices\n pHTN - on inhaled iloprost and sildenafil\n Meds on Tx:\n Cipro prophy, sc hep, iloprost, lansoprazole, synthroid, rifaximin,\n sildenafil, spironolactone\n F: rheumatic heart disease\n Occupation: diability\n Drugs:\n Tobacco: quit 1 yr ago\n Alcohol: quit 11 yrs ago\n Other: lives with mother\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 93 (93 - 93) bpm\n BP: 138/82(95) {138/82(95) - 138/82(95)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.6 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 17.3 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 127\n 27.4\n 11.2\n [image002.jpg]\n Other labs: PT / PTT / INR://inr 2.2\n CXR\n ett 2 cm above carina, low lung volumes, no acute infiltrate or\n volume overload\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Comments:\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:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2147-11-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 424919, "text": "Chief Complaint: respiratory arrest, altered mental status\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 41 yr old man with pHTN ESLD (etoh and hep c) presented initially on\n . On he was in MICU for - intubated, head CT neg, Rx with\n lactulose and cleared and extubated. Negative diagnosic paracentecis\n was negative. Called out to 10. 24 after called out was found\n unresponsive again. Intuabted on floor brought to MICU Green. Chest CT\n neg for PNA or asp. Neuro consult- head CT and MRI- mild abnormality in\n hypothalamuc. 24 hrs in ICU and called back out again. Had done well on\n the floor since then but issues have been management of fluids.\n Restarted aldactone. This am was found unresponsive. ABG: 7.52/24/74 -\n but was intubated for airway protection. Hemodynamics stable. Tx to\n MICU for further management.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 Hep C\n ETOH cirrhosis\n Hypothyroid\n Grade 1 eso varices\n pHTN - on inhaled iloprost and sildenafil\n Meds on Tx:\n Cipro prophy, sc hep, iloprost, lansoprazole, synthroid, rifaximin,\n sildenafil, spironolactone\n F: rheumatic heart disease\n Occupation: diability\n Drugs:\n Tobacco: quit 1 yr ago\n Alcohol: quit 11 yrs ago\n Other: lives with mother\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 93 (93 - 93) bpm\n BP: 138/82(95) {138/82(95) - 138/82(95)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.6 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 98%\n ABG: ////\n Ve: 17.3 L/min\n Physical Examination\n Gen: intubated, but min responsive\n HEENT: ETT in place,\n CV: RR, nl s1, mildly loud P2\n Chest: CTA bilat\n Abd: distended, =BS not tender\n Ext: no edema\n Neuro: opens eyes to voice and tactile stim, moves ext, slow to\n respond,\n Labs / Radiology\n 127\n 27.4\n 80\n 1\n 27\n 17\n 93\n 3.9\n 120\n 11.2\n [image002.jpg]\n Other labs: PT / PTT / INR://inr 2.2\n ALT 86, AST 148, LDH 340, alk phos 148, t bili 6.1\n Ca 8.1, p 2.1, mg 2.1 alb 2.7\n CXR\n ett 2 cm above carina, low lung volumes, no acute infiltrate or\n volume overload\n Assessment and Plan\n 1. Recurrent AM altered mental statusand resp insufficiency: DDx\n has always been hepatic encephalopathy with intermittent lactulose.\n However I wonder about a component of sleep disordered breathing\n with\n his anatomy, abd distension, pHTN\n may be at risk. Would recc formal\n sleep study while in house to eval for this\n need noc ventilation.\n Plan is to switch to PSV, watch closely, lactulose for B<\n Since he has been imaging head CT x 2 and MRI this admit, and he is\n coming around hold off for now/\n 2. HypoNa: stop the spironolactone for now, trend his Na in \n hrs, if persistently give NS,\n 3. Anemia: near baseline, trend\n 4. pHTN: keep on sildenafil, find out if iloprost can be given\n through vent, if not hold and resume post extubation\n ICU Care\n Nutrition: NPO in anticipation of extubation\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Comments:\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: ppi\n VAP: HOB chlorhex,\n Communication: with pt and mother\n status: Full code\n Disposition: ICU\n Total time spent: 45\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426512, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426513, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management; pt will stay in\n MICU 7 for bs, auto-set at HS for ? central apnea, ongoing discussion ?\n trach\n" }, { "category": "Physician ", "chartdate": "2147-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426614, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Peritoneal fluid with GPCs --> coag negative staph, likely contaminant\n Unable to get iloprost.\n Viagra resumed\n Diuretics resumed\n On CPAP overnight\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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 08:06 AM\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: 35.6\nC (96\n HR: 93 (78 - 116) bpm\n BP: 111/56(69) {90/54(61) - 126/82(89)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,100 mL\n 270 mL\n PO:\n 1,010 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,025 mL\n 255 mL\n Urine:\n 1,025 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Nad, a/o x3, cn 2-12 grossly intact, icteric sclera, abd soft, lungs\n clear, no le edema.\n Labs / Radiology\n 91 K/uL\n 8.8 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo M with pulmonary hypertension, ESLD on transplant list with Hep C\n cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with his\n fourth episode of altered mental status requiring intubation for airway\n protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x4 on floor. DDX: hepatic encephalopathy,\n OSA or other sleep disordered breathing.\n - lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n - possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n lasix and spironolactone\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold sildenifil; restart iloprost..\n ICU Care\n Nutrition: po feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: ppi\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: icu\n" }, { "category": "Nursing", "chartdate": "2147-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425956, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n Altered mental status\n Assessment:\n Patient unresponsive since morning, around 1500 hrs, patient more\n awake , moving all extremities but does not follow any commands.\n ,gasping, copious secretion.. Pupils are mm dilated, yellowish,\n sluggishly reactive to light. . MD notified.\n Action:\n Will cont monitoring his mental status. No sedation to be given.\n Response:\n More awake towards evening but not following any commands\n Plan:\n Will cont monitoring mental status closely.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high 90\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for white thin frothy copious to moderate\n secretion. MD notified. ABG repeated X3. Around 1500 hrs, patient is\n more awake & gasping. ABG repeated. IVF started @ 125 ml/hr for 1000\n ml.\n Response:\n F/U serial ABG. Last ABG : 7.49/22/69/17. RR 12-18 bpm.\n Plan:\n Continue monitoring his resp status & F/U with ABG\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 126, urine is dark amber 20-30 ml/hr.\n Action:\n IVF (0.9% NS) started @ 125 ml/hr for 1000 ml. Holding Lasix for now.\n Urine electrolyte sent.\n Response:\n No immediate response.\n Plan:\n Next lytes at 1900 hrs. Follow sodium closely.\n Impaired skin integrity\n Assessment:\n Action:\n Will cont monitoring his mental status. No sedation to be given.\n Response:\n More awake towards evening but not following any commands\n Plan:\n Will cont monitoring mental status closely.\n" }, { "category": "Nursing", "chartdate": "2147-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425957, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n Altered mental status\n Assessment:\n Patient unresponsive since morning, around 1500 hrs, patient more\n awake , moving all extremities but does not follow any commands.\n ,gasping, copious secretion.. Pupils are mm dilated, yellowish,\n sluggishly reactive to light. . MD notified.\n Action:\n Will cont monitoring his mental status. No sedation to be given.\n Response:\n More awake towards evening but not following any commands\n Plan:\n Will cont monitoring mental status closely.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high 90\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for white thin frothy copious to moderate\n secretion. MD notified. ABG repeated X3. Around 1500 hrs, patient is\n more awake & gasping. ABG repeated. IVF started @ 125 ml/hr for 1000\n ml.\n Response:\n F/U serial ABG. Last ABG : 7.49/22/69/17. RR 12-18 bpm.\n Plan:\n Continue monitoring his resp status & F/U with ABG\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na+ 126, urine is dark amber 20-30 ml/hr.\n Action:\n IVF (0.9% NS) started @ 125 ml/hr for 1000 ml. Holding Lasix for now.\n Urine electrolyte sent.\n Response:\n No immediate response.\n Plan:\n Next lytes at 1900 hrs. Follow sodium closely.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm echymotic.. Left hip is reddened.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n Awaiting.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity.\n" }, { "category": "Nursing", "chartdate": "2147-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426076, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management.\n Altered mental status\n Assessment:\n Patient had been unresponsive from 1900 to around 0330 hrs, patient is\n now awake , moving all extremities and follows commands. Pt. continues\n to have copious amt\ns of secretions.. Pupils are now 4mm down from 6mm\n at the beginning of this shift. Yellowish, sluggishly reactive to\n light. . MD notified.\n Action:\n Will cont monitoring his mental status. No sedation to be given, until\n 0330 and when Pt. awoke and needed to be placed on Propofol\n 10mcg/kg/min for sedation.\n Response:\n Pt. awake since 0330 and following any commands Pt. then placed on\n Propofol gtt.\n Plan:\n Will cont monitoring mental/resp status closely.\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Decreased sensorium secondary hepatic encephalopathy, LFT\ns elevated.\n & coagulopathic. Abdomen firm distended.\n Action:\n lactulose 60 mlTID . NPO. Mushroom cath in.\n Response:\n Loose stool noted.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care\n w/barrier cream. Next set of lab at 1900 hrs. Holding Lasix for now.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high >95\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for thick yellowish secretions in copious to\n moderate amt\ns. MD notified.. Around 0330 hrs, patient is awake and\n appropriate.\n Response:\n Pt. placed on Propofol gtt for sedation.\n Plan:\n Continue monitoring his resp status & Discuss possible trach procedure\n later this am.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n No change at this time.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity.\n Possible trach procedure later on today. Pt. is unaware of these plans\n as of this time. Otherwise, Pt. remains on Propofol at 10mcg/kg/min.\n Prior to sedation Pt. was completely appropriate, nodding, and mouthing\n words.\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 425065, "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 INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n Extubated well\n Abdominal pain this AM and KUB concerning for SBO versus ileus. Plan\n for abd CT and Surgery consulted.\n History obtained from Patient\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lactulose,\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 Gastrointestinal: Abdominal pain\n Flowsheet Data as of 08:30 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 (97.6\n HR: 107 (79 - 112) bpm\n BP: 110/65(75) {86/40(51) - 126/67(78)} mmHg\n RR: 14 (9 - 20) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 330 mL\n PO:\n 270 mL\n 330 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 260 mL\n Urine:\n 730 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\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: (Breath Sounds: Diminished: )\n Abdominal: Distended, Tender: , hypoactive bowel sounds\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 131 K/uL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n KNOWLEDGE DEFICIT\n 1. Ileus/SBO: KUB concerning, and he has abdominal pain, will get\n abd CT and surgical consult\n holding off on NGT at present as not\n vomiting and does have known varices, but will place if\n 2. pHTN: due to NPO status not getting sildenafil, so needs to\n take in haled iloprost and will restart sildenafil ASAP\n 3. HypoNatremia: low urine Na, likely dry, start NS at 100 cc/hr\n amd repeat Na this afternoon to make sure\n 4. Cirrhosis: will give pr lactulose once abd CT does not show\n complete obstruction\n ICU Care\n Nutrition: NPO for SBO at present will advance\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt and hepatology\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2147-11-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 425090, "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 INVASIVE VENTILATION - START 08:00 AM\n INVASIVE VENTILATION - STOP 04:49 PM\n Extubated without difficulty. Did not wear BIPAP overnight.\n Abdominal pain this AM and KUB concerning for SBO versus ileus. Plan\n for abd CT and Surgery consulted.\n History obtained from Patient\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lactulose,\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 Gastrointestinal: Abdominal pain\n Flowsheet Data as of 08:30 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 (97.6\n HR: 107 (79 - 112) bpm\n BP: 110/65(75) {86/40(51) - 126/67(78)} mmHg\n RR: 14 (9 - 20) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 680 mL\n 330 mL\n PO:\n 270 mL\n 330 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 730 mL\n 260 mL\n Urine:\n 730 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -50 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,022 (979 - 1,069) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.51/24/292/17/-1\n Ve: 8.7 L/min\n PaO2 / FiO2: 973\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Diminished: , no wheezes\n Abdominal: Distended, Tender: , hypoactive bowel sounds, no rebound or\n guarding\n Skin: warm\n Neurologic: alert and conversant\n Labs / Radiology\n 9.7 g/dL\n 131 K/uL\n 114 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 98 mEq/L\n 125 mEq/L\n 28.8 %\n 10.9 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n WBC\n 10.9\n Hct\n 28.8\n Plt\n 131\n Cr\n 1.1\n 1.0\n 1.1\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n Other labs: PT / PTT / INR:21.9/76.0/2.1, ALT / AST:89/164, Alk Phos /\n T Bili:150/8.3, Albumin:2.9 g/dL, LDH:328 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n .H/O ALKALOSIS, RESPIRATORY\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n 1. Ileus/SBO: KUB concerning, and he has abdominal pain, will get\n abd CT and surgical consult\n holding off on NGT at present as not\n vomiting and does have known varices, but will place if worsening or CT\n more concerning.\n 2. pHTN: due to NPO status not getting sildenafil, so needs to\n take in haled iloprost and will restart sildenafil ASAP\n 3. HypoNatremia: low urine Na, likely dry, start NS at 100 cc/hr\n amd repeat Na this afternoon to make sure Na rising\n 4. Cirrhosis: will give pr lactulose once abd CT does not show\n complete obstruction\n Remining issues as per Housestaff notes\n ICU Care\n Nutrition: NPO for possible SBO at present will advance\n Glycemic Control:\n Lines:\n 20 Gauge - 08:00 AM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt and hepatology\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2147-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426256, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Significant Events :\n ****** Extubated at 11 00\n hrs electively. Prpofol off.\n ****** On room air since\n 1500 hrs, Satting at high 90\n ***** Sitting up at chair\n comfortably.\n ***** patient is alert,\n oriented X3 , appropriate.\n ***** LR off ,patient able to\n drink & eat .\n ****** Plan to place on CPAP\n at night.\n Iloprost ( patient\ns own medication) 1 amp is handed over to patient/\n family members.\n Inability to protect airway\n Assessment:\n Received On vent PS/50%/. satting at high >95\ns. ABG with resp\n alkalosis. Extubated at 1100 hrs. Was on face tent. Room air since\n 1500 hrs.\n Action:\n Electively extubated at 1100 hrs successfully. Placed on face tent.\n After that. On room air since 1500 hrs.\n Response:\n Satting at high 90\ns on room air. Denied SOB. Sitting up at chair.\n Plan:\n Continue monitoring his resp status. Will place on CPAP at night .\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen firm distended, ascittis. hepatic encephalopathy, LFT\n elevated. & coagulopathic. H/O epistaxis.\n Action:\n lactulose 60 mlTID ( scheduled) Lactulose 60 ml Q2 hr PRN X1 given.\n Up to BSC X1.\n Response:\n Small Loose stool X1. Sitting Up at chair.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care w/\n barrier cream.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high >95\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for thick yellowish secretions in copious to\n moderate amt\ns. MD notified.. Around 0330 hrs, patient is awake and\n appropriate.\n Response:\n Pt. placed on Propofol gtt for sedation.\n Plan:\n Continue monitoring his resp status & Discuss possible trach procedure\n later this am.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened. Bruises at rt upper chhek from Adhesive tape.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n No change at this time.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity. Sitting\n up at chair.\n" }, { "category": "Nursing", "chartdate": "2147-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 424987, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n Hepatic encephalopathy\n Assessment:\n Pt sedated on admission after receiving succs 100/etomidate 14mg\n pre-intubation, slowly became alert, responsive and following\n commands, pt extubated to 50% face tent, A,A,O x3 upon extubation\n Action:\n received total 60ml lactlose x3, sedation held, FIB placed on\n admission for small amt golden stool\n none since; 1645 pt extubated to\n 50% face tent\n Response:\n A,A,O x3 upon extubation, no response to lactulose, visiting with\n family\n Plan:\n Cont monitor neuro status, lactulose as ordered to stool, MD\ns aware of\n no response to lactulose.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium continues to drift lower - 120 at 1230, condom cath in place\n no urine output since admission at 0800\n Action:\n Holding diuretics, restricting free H2O\n Response:\n unchanged\n Plan:\n Cont to follow Na per MICU team orders, obtain urine lytes when sample\n available, scan bladder to assess for urinary retention vs oliguria.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n LFT\ns remain elevated\n followed by Dr from transplant team per\n family\n Action:\n Received Lactulose 60 ml x 4since since CCU admission\n Response:\n No stool thus far\n Plan:\n Cont 60ml q 2hr until stooling, rectal bag in place.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Hx pulmonary HTN\n Action:\n Receiving usual dose Sildenafil, Iloprost on hold for now\n family\n states it is locked on nursing unit 10\n Response:\n Sats 100% on 50% face tent post extubation, no c/o SOB\n Plan:\n Continue meds as ordered, F/U with MICU team regarding restarting\n iloprost.\n Knowledge Deficit\n Assessment:\n Pt/mother asking appropriate questions regarding need for multiple\n intubations\n Action:\n Pt and family spoke with MICU team regarding plan of care to observe\n overnight and assess pt while sleeping -\n Response:\n Patient , mother and aunt appear to understand plan of care\n Plan:\n Cont to f/u, Keep pt/family informed of patients condition and plan,\n reassess need for further education.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425216, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Abdominal pain (including abdominal tenderness)\n Assessment:\n No further abd discomfort . abd less distended. amt of acites\n present. Up to commode for 800cc of liq stool\n Action:\n Evening dose of lacutose held. MDs aware.\n Response:\n Additional bm very small.\n Plan:\n Continue lacturlose in am. Evaluate pt for paracenthesis.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pm labs w/ Na+122, K+3.6, slt metabolic acidosis.\n Action:\n Potassium replaced. Pt on 1500cc fluid restriction. Clr liq diet D/C\n restarted on solids.\n Response:\n Plan:\n Continue 1500cc fluid restriction.\n Hepatic encephalopathy\n Assessment:\n Alert and oriented. Tired and feeling sleepy due to not sleeping Sat\n pm.\n Action:\n Continue lactulose in am.\n Response:\n Last 24hrs w/ 3300ccof liq stool.\n Plan:\n monitor for any mental status changes.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n On Sildenafil Citrate and restarted on iloprost inhaler; pt taking own\n iloprost\nverified by pharmacy and doses locked in pt\ns bin in\n omnicell, pt\ns mother has procured more doses and will bring to\n hospital tomorrow\n Response:\n Pt had a pm does of iloprost, tol well. Pt unable to use iloprost.\n Mother usually administers tx at home. Resp therapist to administer\n while in hospital.\n Plan:\n Continue meds as ordered and assess response. Teach pt importance of\n med for pulm HTN, and instruct pt on self administeration of iloprost.\n" }, { "category": "Respiratory ", "chartdate": "2147-11-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 425947, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\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: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\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: 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 / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: intubated on for resp failure with 7.5 22 @lip and\n weaned to PSV 5/5 soon after. Pt has large Vts 1.3-1.5L with RR 10-14\n abg shows resp alkalosis team aware\n Assessment of breathing comfort: No claim of dyspnea)\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 Comments: continue on PSV 5/5 as tolerated. Plan to extubate when pt\n become more awake and alert\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": "2147-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425044, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unrespnsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. This am, , pt again found unresponsive/unarrousable\n on 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645.\n Hepatic encephalopathy\n Assessment:\n Pt sedated on admission after receiving succs 100/etomidate 14mg\n pre-intubation, slowly became alert, responsive and following\n commands, pt extubated to 50% face tent, A,A,O x3 upon extubation\n Action:\n received total 60ml lactlose x3, sedation held, FIB placed on\n admission for small amt golden stool\n none since; 1645 pt extubated to\n 50% face tent\n Response:\n A,A,O x3 upon extubation, no response to lactulose, visiting with\n family\n Plan:\n Cont monitor neuro status, lactulose as ordered to stool, MD\ns aware of\n no response to lactulose.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium continues to drift lower - 120 at 1230, condom cath in place\n no urine output since admission at 0800\n Action:\n Holding diuretics, restricting free H2O\n Response:\n unchanged\n Plan:\n Cont to follow Na per MICU team orders, obtain urine lytes when sample\n available, scan bladder to assess for urinary retention vs oliguria.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n LFT\ns remain elevated\n followed by Dr from transplant team per\n family\n Action:\n Received Lactulose 60 ml x 4since since CCU admission\n Response:\n No stool thus far\n Plan:\n Cont 60ml q 2hr until stooling, rectal bag in place.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Hx pulmonary HTN\n Action:\n Receiving usual dose Sildenafil, Iloprost on hold for now\n family\n states it is locked on nursing unit 10\n Response:\n Sats 100% on 50% face tent post extubation, no c/o SOB\n Plan:\n Continue meds as ordered, F/U with MICU team regarding restarting\n iloprost.\n Knowledge Deficit\n Assessment:\n Pt/mother asking appropriate questions regarding need for multiple\n intubations\n Action:\n Pt and family spoke with MICU team regarding plan of care to observe\n overnight and assess pt while sleeping -\n Response:\n Patient , mother and aunt appear to understand plan of care\n Plan:\n Cont to f/u, Keep pt/family informed of patients condition and plan,\n reassess need for further education.\n ------ Protected Section ------\n At 0800 placed #18 foley under sterile conditions after bladder scanner\n revealed > 500ml in bladder. Initial urine output 600 ml clear, amber\n urine.\n Pt w/multiple skin tears on left lower abdomen secondary to multiple\n dressings at old leaking paracentesis site. Area cleansed, skin\n prepped and versiva dressings placed to cover open areas. Dressing\n remained D+I throughout day.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:53 ------\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 425212, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Abdominal pain (including abdominal tenderness)\n Assessment:\n No further abd discomfort . abd less distended. amt of acites\n present. Up to commode for 800cc of liq stool\n Action:\n Evening dose of lacutose held. MDs aware.\n Response:\n Additional bm very small.\n Plan:\n Continue lacturlose in am. Evaluate pt for paracenthesis.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pm labs w/ Na+122, K+3.6, slt metabolic acidosis.\n Action:\n Potassium replaced. Pt on 1500cc fluid restriction. Clr liq diet D/C\n restarted on solids.\n Response:\n Plan:\n Continue 1500cc fluid restriction.\n Hepatic encephalopathy\n Assessment:\n Alert and oriented. Tired and feeling sleepy due to not sleeping Sat\n pm.\n Action:\n Continue lactulose in am.\n Response:\n Last 24hrs w/ 3300ccof liq stool.\n Plan:\n monitor for any mental status changes.\n" }, { "category": "Nursing", "chartdate": "2147-11-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 425213, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n 24hrs of lactulose and no stool. Abd pain. KUB ?ileus vs SBO given\n 30mls gastroview contrast w/ 900cc juice. Up to commode had bileus liq\n stool +undigested food. CT Scan neg. pt back on clr liq.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Chronic acities, large distended abd, soft. Pt w/o further Abd pain\n since multiple stools. Some discomfort from acities.\n Action:\n Response:\n Plan:\n Discuss and evaluate for paracenthesis\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats remain 95-100% on RA, no c/o SOB, tolerating standing, OOB to\n commode w/o increased dyspnea\n Action:\n Restarted Sildenafil po and iloprost inhaler; pt taking own iloprost\nverified by pharmacy and doses locked in pt\ns bin in omnicell, pt\n mother has procured more doses and will bring to hospital tomorrow\n Response:\n Plan:\n Continue meds as ordered and assess response.\n Knowledge Deficit\n Assessment:\n Pt lack of knowledge regarding importance of taking meds especially\n iloprost inhaler\n Action:\n RN, MICU team members and family encouraging pt to comply with meds,\n stressed importance of meds to pulm HTN, reassured patient it would be\n admistered properly, pt reluctant w/many excuses initially stating he\n feels this medication is what caused his episodes unresponsiveness,\n assured pt he was being continuously monitored\n Response:\n Pt used inhaler x 2 with set up from Resp/RN and assistance from\n brother\n :\n Cont mediction ~Q 2hr w/a; 3 doses left\n mother will bring another\n supply in AM.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Am Na+122\n Action:\n 1500cc fluid restriction, especially water\n Response:\n Plan:\n Follow lytes and treat as needed per MICU team.\n Hepatic encephalopathy\n Assessment:\n Awake alert and oriented throughout day, no evidence decreased\n sensorium secondary hepatic encephalopathy,\n Action:\n Response:\n Plan:\n Lactulose as ordered\n" }, { "category": "Respiratory ", "chartdate": "2147-10-27 00:00:00.000", "description": "Generic Note", "row_id": 423117, "text": "TITLE:\n RESPIRATORY CARE:\n Pt admitted to MICU7 s/p respiratory arrest on floors. Orally\n intubated without difficulty, +ETCO2, bilat. BS\ns. Placed on CMV,\n airway pressures stable. See flowsheet for further pt data, will\n follow.\n 06:25\n" }, { "category": "Physician ", "chartdate": "2147-10-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 423123, "text": "Chief Complaint: respiratory failure\n HPI:\n 41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, who originally presented with altered\n mental status hepatic encephalopathy in the setting of decreased\n BMs. There was a question of aspiration event and he was intubated for\n airway protection at an OSH ED. At , he had a CXR without focal\n pulm consolidations. He was admitted to the MICU, where his mechanical\n ventilation was rapidly weaned. He had a diagnostic tap of his ascites\n which was negative for SBP. His mental status improved and he was\n called out to the hepatology floor on . He had a therapeutic tap\n on PM with removal of 4 L clear peritoneal fluid; again no SBP.\n .\n On the evening after his transfer, he was found nonresponsive in\n \"puddle of saliva\". Hypoxic to 80s and not clearly protecting his\n airway. A code blue was called at ~ 5am and he was intubated. BP\n 99/60, HR 105. Fingerstick 123. He was transfered to MICU 7 for\n further care. No new meds, no narcotics or benzos prior to transfer.\n Last lactulose dose 60 ml at 5 pm on .\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n Medications at home:\n 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n 2. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times\n a day: Take up to 4 times per day as needed to have bowel\n movements per day.\n 3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID\n 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a\n day: also known as Revatio.\n 5. Iloprost Inhalation\n 6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID as needed for\n cramps.\n 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY\n 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO BID\n 9. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:\n One (1) Tablet, Chewable PO twice a day.\n 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a\n day: Do not take at same time as Ciprofloxacin.\n 11. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as\n needed for insomnia.\n 12. Spironolactone 300 mg Tablet PO DAILY\n 13. Hyoscyamine Sulfate 0.15 mg Tablet Sig: One (1) Tablet PO\n three times a day as needed for cramps.\n 14. Furosemide 40mg \n .\n Medications in house:\n Levothyroxine Sodium 88 mcg PO DAILY\n Omeprazole 20 mg PO BID\n Ciprofloxacin HCl 250 mg PO Q24H\n Rifaximin 200 mg PO TID\n Furosemide 60 mg PO DAILY\n Sildenafil Citrate 25 mg PO TID\n Heparin 5000 UNIT SC TID\n Iloprost *NF* 2.5 mcg Inhalation Nine times a day. pulmonary\n hypertension - not getting due to availability.\n Lactulose 30 mL PO QID\n Spironolactone 150 mg PO DAILY\n Lactulose 30 mL PO Q2H:PRN\n Past medical history:\n Family history:\n Social History:\n - ESLD ETOH/hepC on transplant list, MELD=22 now. known grade 1\n esophageal varices by endoscopy, no h/o GIB. biopsy proven liver\n cirrhosis in .\n - pulmonary hypertension - RHC in showed the PA pressures at\n baseline were 47/30 mmHg with a mean of 35 mmHg. This decreased to\n 40/20 mmHg with a mean of 30 with 100% oxygen, and similarly decreased\n to 40/23 mmHg with a mean of 30 with inhaled NO with an increase in\n cardiac output and decrease in PVR as noted.\n - hypothyroidism\n - anxiety disorder\n - h/o ETOH and IVDU\n - osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease\n Occupation:\n Drugs: remote history, none currently\n Tobacco: quit smoking this year.\n Alcohol: Quit alcohol use 11 years ago reportedly.\n Other: Lives with his mother.\n Review of systems:\n Constitutional: No(t) Fever\n Integumentary (skin): Jaundice\n Psychiatric / Sleep: encephalopathic\n Flowsheet Data as of 06:32 AM\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: 35.8\nC (96.4\n HR: 101 (97 - 124) bpm\n BP: 131/82(93) {114/70(85) - 141/87(99)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,150 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,030 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 12 cmH2O\n SpO2: 100%\n Ve: 12.7 L/min\n Physical Examination\n General Appearance: jaundiced, sedated/intubated\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, pupils 5->4\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 3+, Left: 3+, Clubbing\n Skin: Not assessed, Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 100 K/uL\n 9.8 g/dL\n 106 mg/dL\n 0.9 mg/dL\n 23 mg/dL\n 23 mEq/L\n 101 mEq/L\n 4.3 mEq/L\n 134 mEq/L\n 29.0 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A11/5/ 07:51 PM\n \n 10:20 P11/5/ 07:57 PM\n \n 1:20 P11/6/ 04:11 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 11.7\n 13.4\n Hct\n 27.9\n 29.0\n Plt\n 94\n 100\n Cr\n 0.8\n 0.9\n TC02\n 26\n Glucose\n 100\n 106\n Other labs: PT / PTT / INR:20.8/41.6/2.0, ALT / AST:67/122, Alk Phos /\n T Bili:145/8.5, Differential-Neuts:81.5 %, Lymph:8.5 %, Mono:8.6 %,\n Eos:1.2 %, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:426 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n studies:\n CXR (post intubation): ETT low (~1 cm above carina -> repositioned);\n poor inspiration, overall unchanged.\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and echogenic with a nodular contour consistent with the\n patient's known history of cirrhosis. The pancreas is not visualized.\n The gallbladder appears collapsed with a thickened wall. Multiple\n echogenic foci seen within are consistent with shadowing calcified\n gallstones as previously described on prior CT. A stone may possibly be\n within the gallbladder neck. No inhepatic bilary ductal dilation is\n seen. The common bile duct is not completely assessed but proximally\n measures 3mm. The portal vein is patent with hepatopetal flow.\n IMPRESSION:\n Limited study due to marked ascites.\n 1. Cirrhotic, shrunken liver.\n 2. Thickened, collapsed gallbladder with multiple shadowing echogenic\n foci consistent with calcified gallstones. Possible stone within the\n neck. .\n .\n LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: The liver is\n shrunken and nodular in contour compatible with history of cirrhosis.\n There is a large amount of abdominal ascites, unchanged compared to the\n study from one day prior. No intra-or extra-hepatic biliary dilatation\n noted. The gallbladder is collapsed and the wall again is noted to be\n relatively thickened. Multiple shadowing echogenic foci fill the\n gallbladder and potentially the gallbladder neck and are compatible\n with gallstones. Overall, this has not changed compared to the study 24\n hours prior. The common bile duct is not dilated and measures 2 mm in\n diameter.\n IMPRESSION:\n 1. Unchanged cirrhotic shrunken liver.\n 2. Unchanged large volume of ascites.\n 3. Persistent, thickened, collapsed gallbladder with multiple stones.\n No evidence of intra- or extra-hepatic biliary dilatation.\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n 41 yo male with ESLD with cirrhosis, pulm HTN, originally admitted\n after being intubated for airway protection from AMS thought to\n hepatic encephalopathy. Now found unresponsive with hypoxia and\n respiratory failure.\n .\n # Respiratory failure: Unclear etiology but likely related to mental\n status, possibly associated with aspiration or mucous plugging.\n - vent\n - vent precautions\n - sedation\n - ...\n .\n # delta MS - likely hepatic encephalopathy as per mother pt only\n having 2 BM/day. No obvious source of infection, though no UA in OMR\n (done at OSH). No obvious recent GIB, HCT ~baseline. Pt also recently\n started on cyclobenzaprine, mag, and hyoscyamine, and trazadone which\n may have contributed. Trigger may have been viral gastroenteritis\n resulting in n/v and inability to take lactulose. Currently mental\n status improving on lactulose and rifaximin only.\n - f/u SBP cultures.\n - titrate lactulose for goal BM/day, has had x 2 today.\n - avoid sedating medications.\n - send UA/UCx.\n - guaic stools.\n .\n .\n # ESLD: ETOH/HepC, MELD=22 now. +h/o hepatic encephalopathy, known\n varices, followed by Dr. , on transplant list. +ascites, no SBP\n presently. creatinine wnl. TBIL elevated (6.4->8.4), with RUQ USN\n showing ?stone at GB neck. DBIL 2.4, suggesting mostly unconjugated\n hyperbilirubinemia.\n - continue lactulose/rifaximin as above.\n - unclear why pt not on nadalol.\n - guaic stools.\n - continue lasix and spironolactone.\n - f/u paracentesis fluid culture.\n - continue cipro prophylaxis.\n - likely therapeutic paracentesis in AM.\n - add-on hemolysis labs given indirect hyperbilirubinemia.\n - d/w liver attg need for HIDA given ?stone with elevated TB, CBD was\n 3mm on RUQ USN, no intrahepatic biliary dilation.\n - will plan for repeat RUQ USN tonight, to examine specifically for\n cholecystitis given ?stone at GB neck on USN yesterday. if negative,\n and TBIL still rising without evidence of hemolysis, then will consider\n HIDA.\n .\n # pulmonary HTN: pt breathing comfortably on RA presently. concern for\n rebound hypertension given that pt has not been on iloprost inhalers\n for past 2-3 days. mother plans to bring inhaler from home on .\n - monitor pt's O2 sats and BP closely. if rebound pulmonary HTN occurs,\n would expect decreased BP decreased RV output. if symtoms of RV\n failure develop, would consider flolan.\n - avoid agressive diuresis until pt can restart inhalers to provide BP\n cushion. continue home regimen of diuretics.\n - continue sildenafil.\n .\n # tachycardia: sinus tachycardia. ddx include intravascular depletion\n dehydration (+ppor PO intake, n/v), liver disease, anemia or right\n heart failure. ddx also includes pain, anxiety which pt denies. no\n evidence of RV failure presently given lack of JVD. Utox on \n negative, thus withdrawal less likely.\n - consider liberalizing Na restriction (h/o hyponatremia).\n - d/w liver attg utility of albumin.\n - decrease home regimen of lasix/spirinolactone to lasix 60mg qdaily,\n spirinolactone 150mg qdaily.\n .\n # leukocytosis: +left shift, no obvious source of infection presently,\n could be reactive. no fever. cxr without evidence of aspiration.\n - check UA/UCx.\n - trend fever curve and wbc.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. currently hct\n 29, plt 100, may represent some hemoconcentration.\n - guaic stools.\n - add-on hapto, retic to r/o hemolysis given indirect bilirubinemia.\n - trend HCT.\n .\n # hypothyroidism: TSH remains elevated 6.6->4.9, since on 75mcg\n synthroid.\n - increase levothyroxine to 88mcg/qdaily.\n ICU Care\n Nutrition:\n Comments: NPO, place OGT\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: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2147-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423273, "text": "41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Altered mental status (not Delirium)\n Assessment:\n Patient unresponsive this am on 1mg/hr versed and 25mcgs/hr of\n fentanyl. Pearl sluggishly. Withdraws to pain this am in upper ext as\n day progressed in lower ext as well. Right lower ext with less of a\n withdrawal than left. Weak cough with suctioning. Minimal gag.\n Action:\n Ammonia level checked. Lactulose ordered and given. Head ct ordered\n and done. Neuro consulted. Eeg being done.\n Response:\n Ammonia level high at 286. On lactulose 60cc q 2 hours till starts\n stooling. Has not started stooling yet despite 3 doses of lactulose. 1\n lactulose enema given to get things started. Putting out small amounts\n of golden stool with lactulose enema returns. Head ct neg for bleed per\n team. Awaiting results of eeg. Neuro recommending mri of head and neck.\n Checklist completed and faxed.\n Plan:\n Cont lactulose. MRI of head and neck.\n . Cont lactulose as ordered. Check results of eeg. Monitor neuro\n status. Keep intubated to protect airway till awake . Avoid sedating\n meds.\n .H/O alkalosis, respiratory\n Assessment:\n Ph 7.61/23/188/24 on vent 50% fio2 5 peep and 5 ps. Tv up to 1l.\n breathing . mv 11 liters or greater.\n Action:\n Dr aware. Decision made to decrease ps to 0 to see if this would\n decrease tv of breaths.\n Response:\n Abg 30 min into this was 7.57/26/161/25.\n Plan:\n Continue to monitor abg\ns as ordered.\n Gu- uo down to 20cc/hr x 2hours. Bladder pressure checked. 11. dr \n aware. No tx ordered.\n Mother brought in patient iloprost med for pulmonary htn that\n is in paitent room. This drug can not be given to him while he is on\n the vent as it a a neb. Machine and med in the room. Instructions for\n how to use the nebulizer machine in the front of his blue book.\n Patient\ns mother and brother have been here most of the day. They have\n been updated by this nurse, the micu team and the hepatology team. All\n questions answered.\n" }, { "category": "Nursing", "chartdate": "2147-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423217, "text": "41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Altered mental status (not Delirium)\n Assessment:\n Patient unresponsive this am on 1mg/hr versed and 25mcgs/hr of\n fentanyl. Pearl sluggishly. Withdraws to pain this am in upper ext as\n day progressed in lower ext as well. Weak cough with suctioning.\n Minimal gag.\n Action:\n Ammonia level checked. Lactulose ordered and given. Head ct ordered\n and done. Neuro consulted. Eeg being done.\n Response:\n Ammonia level high at 286. On lactulose 60cc q 2 hours till starts\n stooling. Has not started stooling yet despite 3 doses of lactulose.\n Head ct neg for bleed per team. Awaiting results of eeg.\n Plan:\n Cont lactulose. See what neuro recommends. Cont lactulose as ordered.\n Check results of eeg. Monitor neuro status. Keep intubated to protect\n airway till awake . Avoid sedating meds.\n .H/O alkalosis, respiratory\n Assessment:\n Ph 7.61/23/188/24 on vent 50% fio2 5 peep and 5 ps. Tv up to 1l.\n breathing . mv 11 liters or greater.\n Action:\n Dr aware. Decision made to decrease ps to 0 to see if this would\n decrease tv of breaths.\n Response:\n Abg 30 min into this was 7.57/26/161/25.\n Plan:\n Continue to monitor abg\ns as ordered.\n Mother brought in patient iloprost med for pulmonary htn that\n is in paitent room. This drug can not be given to him while he is on\n the vent as it a a neb. Machine and med in the room. Instructions for\n how to use the nebulizer machine in the front of his blue book.\n Patient\ns mother and brother have been here most of the day. They have\n been updated by this nurse, the micu team and the hepatology team. All\n questions answered.\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423397, "text": "Chief Complaint:\n 24 Hour Events:\n - Evaluated by neurology who were concerned about RLE weakness and so\n recommended urgent brain MRI, neck MRA.\n - Became progressively tachycardic to 140s which did not respond to\n versed 3 mg, 500 cc fluid bolus, PS 5/5. He responded to fentanyl\n bolus.\n - Ammonia found to be 286\n - Head CT showed ?degenerative disk disease, reccommended lateral film\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:05 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: 37.4\nC (99.4\n HR: 121 (96 - 141) bpm\n BP: 134/85(101) {92/52(66) - 139/85(101)} mmHg\n RR: 11 (10 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 71 mL\n PO:\n TF:\n IVF:\n 948 mL\n 71 mL\n Blood products:\n Total out:\n 835 mL\n 815 mL\n Urine:\n 835 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -745 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 850 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.43/30/431/18/-2\n Ve: 11 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\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: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +ascites\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 123 K/uL\n 10.0 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\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": "2147-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423398, "text": "Chief Complaint:\n 24 Hour Events:\n - Evaluated by neurology who were concerned about RLE weakness and so\n recommended urgent brain MRI, neck MRA.\n - Became progressively tachycardic to 140s which did not respond to\n versed 3 mg, 500 cc fluid bolus, PS 5/5. He responded to fentanyl\n bolus.\n - Ammonia found to be 286\n - Head CT showed ?degenerative disk disease, reccommended lateral film\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:05 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: 37.4\nC (99.4\n HR: 121 (96 - 141) bpm\n BP: 134/85(101) {92/52(66) - 139/85(101)} mmHg\n RR: 11 (10 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 71 mL\n PO:\n TF:\n IVF:\n 948 mL\n 71 mL\n Blood products:\n Total out:\n 835 mL\n 815 mL\n Urine:\n 835 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -745 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 850 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.43/30/431/18/-2\n Ve: 11 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic\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: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +ascites\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 123 K/uL\n 10.0 g/dL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 41 yo male with ESLD with cirrhosis, pulm HTN, originally admitted\n after being intubated for airway protection from AMS thought to\n hepatic encephalopathy. Now found unresponsive with hypoxia and\n respiratory failure.\n .\n # Respiratory failure: Intubated after found unresponsive. Unclear\n etiology but likely related to encephalopathy/delta MS. \n intubation in 2 days. No hemodynamic compromise.\n - management of altered mental status/encephalopathy below.\n - vent: check ABG and adjust accordingly; AC ventilation for now.\n - VAP precautions\n - Eval for other causes of respiratory distress (other than delta MS);\n checking CXR, infectious workup, check ECG.\n .\n # Encephalopathy/delta MS - likely hepatic encephalopathy.\n Initially suspected to be encephalopathic at home as per mother pt only\n having 2 BM/day. No obvious recent GIB, no evidence of infection (SBP\n ruled out, CXR without infiltrate, urine with 29 WBCs but bloody. Pt\n had been recently started on cyclobenzaprine, mag, and hyoscyamine, and\n trazadone which may have contributed at home. Urine tox neg in ED;\n serum tox checked only for etoh and negative. Flows normal on\n ultrasound.\n - repeat tox screen and infectious workup.\n - f/u peritoneal fluid cultures.\n - Place OGT; lactulose Q1-2H until stools, then Q4-6 hours.\n - avoid sedating medications, titrate off fent and versed early this\n AM.\n - guaiac stools.\n - Check head CT this AM given acute change and coagulopathy.\n - consider eeg - ?could this be seizure.\n - check ammonia to trend.\n .\n # Respiratory alkalosis. ABG currently ph 7.56/ pCO2 28. Also noted\n to have alkalosis in the past. ? related to liver disease /cirrhosis\n and ascites.\n - decrease TV on vent vs. trial of PS.\n - Checking serum tox to r/o salicylates.\n .\n # ESLD: ETOH/HepC. +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list. +ascites, no SBP presently.\n Therapeutic para yesterday.\n - continue lactulose/rifaximin as above.\n - ?should he be on nadolol.\n - guaiac stools.\n - hold Lasix and spironolactone this AM given high lactate to ensure BP\n stability; likely restart this PM.\n - continue cipro prophylaxis for SBP.\n .\n # pulmonary HTN: on sildenifil and iloprost at home; concern for\n rebound hypertension given that pt has not been on iloprost inhalers\n for past 2-3 days. No hemodynamic compromise to suggest that\n respiratory distress was consequence of pulmonary hypertension\n decompensation.\n - attempting to get iloprost inhalers.\n - continue sildenafil.\n .\n # leukocytosis: +left shift, no obvious source of infection presently,\n could be reactive. no fever. cxr without evidence of aspiration.\n - recheck in MICU\n - check UA/UCx, blood cultures.\n - trend fever curve and wbc.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Retic-ing\n well.\n - guaiac stools.\n - trend HCT.\n .\n # hypothyroidism: TSH was elevated 6.6->4.9, since on 75mcg\n synthroid. increased levothyroxine to 88mcg/qdaily earlier during\n admission.\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control:\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots\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": "2147-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423412, "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 URINE CULTURE - At 08:18 AM\n EEG - At 02:46 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:58 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 (98.5\n HR: 118 (96 - 141) bpm\n BP: 125/74(90) {92/52(66) - 139/85(101)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 180 mL\n PO:\n TF:\n IVF:\n 948 mL\n 80 mL\n Blood products:\n Total out:\n 835 mL\n 985 mL\n Urine:\n 835 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -806 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,026 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.43/30/431/18/-2\n Ve: 7.7 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No acute distress, Thin, icteric\n Eyes / Conjunctiva: PERRL\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended, large\n asites\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x1, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 123 K/uL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy,\n will look for intracranial bleed (esp with significant respi alkalosis)\n with head CT vs progressive hepatic encephalopathy vs seizure (unclear\n why he would seize unless alkalosis has caused him to do so).\n - PS ventilation for now\n - avoid sedation\n - Head and Chest CT\n Neurology consult if head CT negative for bleed and EEG not revealing\n for seizure\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS:\n - Cont lactulose after placement of OG\n - Head CT and Chest CT to look for bleed and source of infection.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - neurology consult\n - EEG\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO when able\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423419, "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 URINE CULTURE - At 08:18 AM\n EEG - At 02:46 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n > Markedly improved mental status\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:58 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 (98.5\n HR: 118 (96 - 141) bpm\n BP: 125/74(90) {92/52(66) - 139/85(101)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 180 mL\n PO:\n TF:\n IVF:\n 948 mL\n 80 mL\n Blood products:\n Total out:\n 835 mL\n 985 mL\n Urine:\n 835 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -806 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,026 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.43/30/431/18/-2\n Ve: 7.7 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No acute distress, Thin, icteric\n Eyes / Conjunctiva: PERRL\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended, large\n asites\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2, Movement: Purposeful, not able top move the\n right leg and increasd patellar reflex on the right. Downgoing toes\n bilateral, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 123 K/uL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n CXR : improved lung volumes compared to . no obvious\n infiltrate.\n Sputum : GPR and GPC in pairs and chains\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status. Extubated . Sputum culture is\n likely to be oral flora base on appearance of CXR and clinical\n improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Restart lasix and spironolactone\n - Will likely need a repeat paracentesis in the near future will confer\n with liver service.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K for 3 day\n - F/ read of the MRI\n > Right leg weakness: Neuro team concerned for right leg weakness, will\n f/u MRI/A still with decreased right leg . Appreciate neurology input:\n he still has some right lower leg weakness\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO when able\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots, INR 2.0\n Stress ulcer: PPI\n VAP: HOB elevation, Aspiration precautions.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422903, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS. At the OSH, he was\n intubated for airway protection. CXR was negative for infiltrate, u/a\n was clean and CT of the head was negative for an acute process.\n Events;Extubated at 2230\n Altered mental status /ESLD secondary to alcohol and hep C\n Assessment:\n Extubated at 2230 was not on any sedation,lethargic oriented to self\n and place,denies any pain,anxious and calling out for\n mother,MAE,afebrile,tachycardic 120-130,Ascitis.\n Action:\n Pt was successfully extubated,on 40% FM weaned off now on\n RA, LS clear/diminished sats upto 95%.In hepatic encephalopathy-hold\n sedating medications, mental status slowly improving,denies any pain pt\n was anxious after extubation,called his mother and left the\n message,may visit later during the day. On rifaximine and lactulose\n for ESLD,lactulose regular diose and Q2H prn given no BM so far\n Response:\n Pt slowly improving on MS\n :\n Clear liquids started- Continue lactulose,hold sedatimg meds,f/u\n cultures,paracentesis,call out to floor if remains stable.\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 423395, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\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\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422892, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS. At the OSH, he was\n intubated for airway protection. CXR was negative for infiltrate, u/a\n was clean and CT of the head was negative for an acute process.\n Events;Extubated at 2230\n Altered mental status /ESLD secondary to alcohol and hep C\n Assessment:\n Extubated at 2230 was not on any sedation,lethargic oriented to self\n and place,denies any pain,anxious and calling out for\n mother,MAE,afebrile,tachycardic 120-130,Ascitis.\n Action:\n Pt was successfully extubated,on 40% FM now,LS clear/diminished sats\n upto 95%.In hepatic encephalopathy-hold sedating medications, mental\n status slowly improving,denies any pain pt was anxious after\n extubation,called his mother and left the message,may visit later\n during the day. On rifaximine and lactulose for ESLD\n Response:\n Plan:\n Continue lactulose,hold sedatimg meds,f/u cultures,paracentesis,call\n out to floor if remains stable.\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422894, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS. At the OSH, he was\n intubated for airway protection. CXR was negative for infiltrate, u/a\n was clean and CT of the head was negative for an acute process.\n Events;Extubated at 2230\n Altered mental status /ESLD secondary to alcohol and hep C\n Assessment:\n Extubated at 2230 was not on any sedation,lethargic oriented to self\n and place,denies any pain,anxious and calling out for\n mother,MAE,afebrile,tachycardic 120-130,Ascitis.\n Action:\n Pt was successfully extubated,on 40% FM now,LS clear/diminished sats\n upto 95%.In hepatic encephalopathy-hold sedating medications, mental\n status slowly improving,denies any pain pt was anxious after\n extubation,called his mother and left the message,may visit later\n during the day. On rifaximine and lactulose for ESLD\n Response:\n Pt slowly improving on MS\n :\n NPO - Continue lactulose,hold sedatimg meds,f/u\n cultures,paracentesis,call out to floor if remains stable.\n" }, { "category": "Nursing", "chartdate": "2147-10-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423269, "text": "41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Altered mental status (not Delirium)\n Assessment:\n Patient unresponsive this am on 1mg/hr versed and 25mcgs/hr of\n fentanyl. Pearl sluggishly. Withdraws to pain this am in upper ext as\n day progressed in lower ext as well. Right lower ext with less of a\n withdrawal than left. Weak cough with suctioning. Minimal gag.\n Action:\n Ammonia level checked. Lactulose ordered and given. Head ct ordered\n and done. Neuro consulted. Eeg being done.\n Response:\n Ammonia level high at 286. On lactulose 60cc q 2 hours till starts\n stooling. Has not started stooling yet despite 3 doses of lactulose. 1\n lactulose enema given to get things started. Putting out small amounts\n of golden stool with lactulose enema returns. Head ct neg for bleed per\n team. Awaiting results of eeg. Neuro recommending mri of head and neck.\n Checklist completed and faxed.\n Plan:\n Cont lactulose. MRI of head and neck.\n . Cont lactulose as ordered. Check results of eeg. Monitor neuro\n status. Keep intubated to protect airway till awake . Avoid sedating\n meds.\n .H/O alkalosis, respiratory\n Assessment:\n Ph 7.61/23/188/24 on vent 50% fio2 5 peep and 5 ps. Tv up to 1l.\n breathing . mv 11 liters or greater.\n Action:\n Dr aware. Decision made to decrease ps to 0 to see if this would\n decrease tv of breaths.\n Response:\n Abg 30 min into this was 7.57/26/161/25.\n Plan:\n Continue to monitor abg\ns as ordered.\n Mother brought in patient iloprost med for pulmonary htn that\n is in paitent room. This drug can not be given to him while he is on\n the vent as it a a neb. Machine and med in the room. Instructions for\n how to use the nebulizer machine in the front of his blue book.\n Patient\ns mother and brother have been here most of the day. They have\n been updated by this nurse, the micu team and the hepatology team. All\n questions answered.\n" }, { "category": "Nursing", "chartdate": "2147-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 423393, "text": "41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Altered mental status (not Delirium)\n Assessment:\n Pt very tachycardic up to the 140\ns, bp stable, pupils fully dilated\n but react briskly. Withdraws to painful stiim will open eyes but not\n track . only moving extr on the bed.Right lower ext with less of a\n withdrawal than left. Weak cough with suctioning. Minimal gag.\n Action:\n Pt given lactulose q 2/hrs until pt began to stool. Pt given several\n boluses of fent/versed to help bring hr down. Pt not having much stool,\n given lactulose enema. Pt had mri of head and neck to r/o stroke.\n Response:\n Pt eventually put lrg amt\ns of loose golden stool after lactulose\n enema. Pt\ns hr came down to the one teens after receiving fent boluses.\n Slowly coming back up. Pt much more awake this am after lactulose.\n Plan:\n Lactulose po d/c\nd, check results of mri. Plan to wean vent and\n possible extubate. Avoid sedation if possible.\n .H/O alkalosis, respiratory\n Assessment:\n Abg\ns improving slowly, suctioning for lrg amt\ns of thick yellow\n secretions. Lung sounds coarse and diminished at the bases.\n Action:\n Dr aware. Decision made to increase ps to 5 to help with\n alkalosis.\n Response:\n Pt tolerating vent change.\n Plan:\n Continue to monitor abg\ns as ordered.\n AM\n" }, { "category": "Physician ", "chartdate": "2147-10-25 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 422888, "text": "Chief Complaint: Respiratory Failure\n Encephalopathy\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 altered mental status this am with nausea and vomiting.\n At OSH--Head CT, Tox screen without abnormalities. He was intubated\n for \"airway protection\" and sent to for further care.\n Here patient had ascites tap showing only 90 WBC's and patient to ICU\n for further care\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Cirrhosis--EtOH and Hep C c/b varicies\n Non Contributory\n Occupation: Unemp\n Drugs: None\n Tobacco: None\n Alcohol: None now\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n 2 BM's/day\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia\n Flowsheet Data as of 10:11 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.2\n HR: 118 (107 - 128) bpm\n BP: 113/73(82) {112/67(79) - 143/94(99)} mmHg\n RR: 14 (13 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -100 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.54/29/205/25/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\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: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended, No(t) Tender:\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 94 K/uL\n 27.9 %\n 9.5 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 25 mEq/L\n 103 mEq/L\n 3.8 mEq/L\n 135 mEq/L\n 11.7 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n WBC\n 11.7\n Hct\n 27.9\n Plt\n 94\n Cr\n 0.8\n TC02\n 26\n Glucose\n 100\n Other labs: PT / PTT / INR:19.9/41.2/1.9, ALT / AST:69/125, Alk Phos /\n T Bili:146/7.7, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:371 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Fluid analysis / Other labs: Tox--+ TCA's\n Imaging: CXR-No infiltrate noted, ETT at 1 cm above carina\n RUQ U/S--ascites and suggestion of stone in CBD, no doppler performed\n Assessment and Plan\n 41 yo male with history of cirrhosis and now admitted with respiratory\n failure and altered mental status. He has a relative paucity of\n symptoms to suggest recent infection and has tap of ascites without\n significant evidence of SBP.\n 1)Altered Mental Status--leading diagnosis is hepatic encephaolopathy\n and do not have clear trigger other than possble recent nausea and\n vomiting perhaps limiting medication effectiveness in the setting of\n decerased BM's\n -Lactulose\n -Hold sedating medications\n -WIll recheck U/S to look for possible portal vein changes.\n 2)Respiratory Failure--minimal evidence of pulmonary insult based on\n history or CXR\n -PSV to \n -Continue to monitor mental status\n -Move to extubation as soon as patient able to respond to simuli and\n ideally commands prior to extubation\n 3)Cirrhosis--patient with significant ascites\n -Continue Lasix\n -Move to tap ascites for therapeutic relief of increased abdominal\n pressure\n -Repeat U/S as above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 06:39 PM\n Comments:\n Prophylaxis:\n DVT: Boots\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 Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-10-25 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 422889, "text": "Chief Complaint: altered mental status\n HPI:\n 41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. He is currently intubated so history taken from\n his mother over the phone and from and chart. The day prior to\n presentation, the patient was complaining of feeling sick and\n nauseated. He vomited several times but did take all of his medications\n per his mother as she gives them to him. She went to check on him the\n morning of presentation and he was unresponsive and gagging on emesis.\n She called EMS. She reports that the patient has been having 2 bowel\n movements per day over the last two days. Denies known fevers, chills,\n diarrhea, abdominal pain. Of note, he has gained significant weight and\n his spironolactone was increased from 100 to 200mg daily and then up to\n 300mg on .\n .\n At the OSH, he was intubated for airway protection. CXR was negative\n for infiltrate, u/a was clean and CT of the head was negative for an\n acute process. He was given lasix 100mg x1 and transferred to ED.\n .\n In our ED, his initial vitals were T 96.4, HR 104, BP 132/87, 100%\n o2sat on vent. He had a repeat CXR to confirm his ETT placement. A RUQ\n u/s showed small stones and marked ascites, and he had a diagnostic\n paracentesis. He was given levo/flagyl empirically and was given\n lactulose.\n .\n Currently, he is on the vent, but following some commands and denies\n pain.\n .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:52 PM\n Heparin Sodium - 08:52 PM\n Other medications:\n 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H\n 2. Lactulose 10 gram/15 mL Solution Sig: One (1) PO four times\n a day: Take up to 4 times per day as needed to have bowel\n movements per day.\n 3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID\n 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a\n day: also known as Revatio.\n 5. Iloprost Inhalation\n 6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID as needed for\n cramps.\n 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY\n 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO BID\n 9. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:\n One (1) Tablet, Chewable PO twice a day.\n 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a\n day: Do not take at same time as Ciprofloxacin.\n 11. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as\n needed for insomnia.\n 12. Spironolactone 300 mg Tablet PO DAILY\n 13. Hyoscyamine Sulfate 0.15 mg Tablet Sig: One (1) Tablet PO\n three times a day as needed for cramps.\n 14. Furosemide 40mg \n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation: disabled\n Drugs: remote IVDU in his teens\n Tobacco: quit earlier this year\n Alcohol: quit 11 years ago but has history of abuse\n Other: lives with his mother\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Nausea, Emesis, No(t) Constipation, 2 BM per day last\n few days\n Integumentary (skin): Jaundice\n Neurologic: No(t) Headache\n Flowsheet Data as of 10:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.2\n HR: 118 (107 - 128) bpm\n BP: 113/73(82) {112/67(79) - 143/94(99)} mmHg\n RR: 14 (13 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -100 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 760 (760 - 1,283) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.54/29/205/25/3\n Ve: 11 L/min\n PaO2 / FiO2: 512\n Physical Examination\n General Appearance: Anxious, jaundice\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\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 No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Rhonchorous: )\n Abdominal: Non-tender, Bowel sounds present, Distended\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Skin: Not assessed\n Neurologic: Follows simple commands, no clonus, no asterixis noted\n Labs / Radiology\n 94 K/uL\n 9.5 g/dL\n 100 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 25 mEq/L\n 103 mEq/L\n 3.8 mEq/L\n 135 mEq/L\n 27.9 %\n 11.7 K/uL\n [image002.jpg]\n \n 2:33 A11/5/ 07:51 PM\n \n 10:20 P11/5/ 07:57 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 11.7\n Hct\n 27.9\n Plt\n 94\n Cr\n 0.8\n TC02\n 26\n Glucose\n 100\n Other labs: PT / PTT / INR:19.9/41.2/1.9, ALT / AST:69/125, Alk Phos /\n T Bili:146/7.7, Lactic Acid:2.2 mmol/L, Albumin:2.6 g/dL, LDH:371 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Fluid analysis / Other labs: OSH labs:\n glucose 118, BUN 19, Cr 0.84, soidum 137, potassium 4.2, cl 102, co2\n 102, albumin 3.4, alk phos 301, ast 199, alt 87, total bili 6.4,\n amlyase 123, lipase 629, calcium 8.8, magnesium 2\n WBC 9.3, HCT 35, MCV 100, Plt 110. INR 1.59\n ammonia 239\n serum alcohol negative\n ABG 7.52/30/111\n urine tox screen negative except for tricyclics\n Imaging: Liver u/s: IMPRESSION:\n Limited study due to marked ascites.\n 1. Cirrhotic, shrunken liver.\n 2. Thickened, collapsed gallbladder with multiple shadowing echogenic\n foci consistent with calcified gallstones. Possible stone within the\n neck.\n .\n CXR: FINDINGS:\n The tip of the ET tube is approximately 14 mm from the carina and may\n need to be repositioned. The NG tube needs to be advanced further.\n The lungs are of low volume, most likely due to poor inspiratory\n effort. The cardiomediastinal silhouette is stable. There are no focal\n pulmonary consolidations.\n Assessment and Plan\n 41 yo M with ESLD from alcohol and hepatitis C on transplant list,\n pulmonary hypertension and hypothyroidism who presents with altered\n mental status.\n # altered mental status: likely secondary to hepatic encephalopathy.\n Per his mother, he has been taking his medications but only having\n about 2 bowel movements per day. DDx also includes infection (CXR clear\n and ascites fluid did not suggest infection and u/a was negative),\n medications (recently started medications for cramping including\n cyclobenzaprine, hyoscyamine and magnesium, some of which may\n contribute to confusion. Was given lactulose in the ED with bowel\n movement afterwards. His mental status seems improved currently.\n -lactulose titrated to bowel movements per day\n -hold sedating medications\n -f/u cultures\n .\n # primary respiratory alkylosis: likely secondary to anxiety or pain\n and he is tachycardic which supports this idea. He denies pain\n currently. Would like to avoid sedating medications in a patient with\n end stage liver disease as I would like to extubate him tonight.\n -monitor ABGs for now. If alkylosis worsens, may need to lower his RR\n with sedation or try to lower pressure support.\n -will likely improve post extubation\n .\n # nausea and vomiting: likely gastroenteritis or could be from new\n medications for muscle spasms including magnesium which dose was\n recently increased.\n -no sign of currently nausea or emesis. Will monitor.\n .\n # ascites: no evidence of infection with WBC low in the ascites fluid.\n He is distended and will need paracentesis.\n -follow up ascites culture\n .\n # ESLD: secondary to alcohol and hepatitis C. Followed by Dr. on\n transplant list. Tbili is more elevated than his baseline of \n (current 7)\n -continue rifaximine, lactulose\n -Hepatology aware and appreciate consult\n -u/s with doppler of the liver\n -continue lasix and spironolactone\n -paracentesis in AM\n .\n # pulmonary hypertension: continue iloprost and sildenafil.\n .\n # respiratory support: currently intubated for airway protection given\n altered mental status.\n -consider pressure support trial\n -would like to extubate tonight if mental status improves.\n .\n # hypothyroidism: continue levothyroxine\n .\n # FEN: NPO for now. Hope to extubate. Received IVF in ED.\n .\n # PPX: heparin SQ for DVT ppx, omeprazole for GI ppx per home\n regimen.\n .\n # Code: full\n .\n # Communication: patient and mother\n .\n # Dispo: ICU for now and likely to floor in AM.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:39 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\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": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422890, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422891, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422893, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS. At the OSH, he was\n intubated for airway protection. CXR was negative for infiltrate, u/a\n was clean and CT of the head was negative for an acute process.\n Events;Extubated at 2230\n Altered mental status /ESLD secondary to alcohol and hep C\n Assessment:\n Extubated at 2230 was not on any sedation,lethargic oriented to self\n and place,denies any pain,anxious and calling out for\n mother,MAE,afebrile,tachycardic 120-130,Ascitis.\n Action:\n Pt was successfully extubated,on 40% FM now,LS clear/diminished sats\n upto 95%.In hepatic encephalopathy-hold sedating medications, mental\n status slowly improving,denies any pain pt was anxious after\n extubation,called his mother and left the message,may visit later\n during the day. On rifaximine and lactulose for ESLD\n Response:\n Pt slowly improving on MS\n :\n NPO -- U/S liver scheduled at 0930 Continue lactulose,hold sedatimg\n meds,f/u cultures,paracentesis,call out to floor if remains stable.\n" }, { "category": "Physician ", "chartdate": "2147-10-27 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 423208, "text": "Chief Complaint: Code Blue on Floor for 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 41 year old male with hx of cirrhossis HCV and EtOh with hepatic\n encephalopathy admitted to MICU from OSH (intubated)\n improved with lactulose, extubated . Notably had a neg paracentesis\n for SBP. No evidence of other tirggers (infection, bleed). Found at 5AM\n in a \"pool of saliva\", sats in the 80%, with pulse and blood pressure,\n normal finger stick. He was intubated for inability to protect airway.\n By report he had been taking lactulose on the floor.\n Patient admitted from: \n History obtained from house officer\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies. Currently on liver transplant\n list (Dr. \n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a\n mean pressure of 8. Notably he had a pulmonary capillary wedge\n pressure of approximately 15 at that time and his cardiac output\n was normal with 6.7 liters per minute, cardiac index of 3.7. His\n pulmonary vascular resistance was nearly normal at 251 and he\n was in sinus rhyth at that time with a heart rate of 90.\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n non contrib\n Occupation: lives with mother\n Drugs: remote\n Tobacco: past\n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 09:02 AM\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: 35.5\nC (95.9\n HR: 106 (97 - 124) bpm\n BP: 119/71(86) {115/69(3) - 119/71(86)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Total In:\n 1,150 mL\n 38 mL\n PO:\n 1,090 mL\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 1,030 mL\n 390 mL\n Urine:\n 730 mL\n 390 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 120 mL\n -352 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,070 (1,070 - 1,070) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: 7.60/23/356/22/2\n Ve: 13.3 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, icteric sclerae\n Head, Ears, Nose, Throat: Normocephalic\n CTA B/l no WRR\n RRR N MRG\n Abd distended and fluid filled. Non tender\n Skin: warm\n Neurologic: Responds to: Not assessed, Oriented (to): x0, Movement: no\n withdrawl to pain. No clonus. Pupils dilated but reactive. + corneals,\n no withdrawl to pain b/l, upgoing toes.\n Labs / Radiology\n 107 K/uL\n 31.0 %\n 10.3 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 20 mg/dL\n 22 mEq/L\n 100 mEq/L\n 4.3 mEq/L\n 131 mEq/L\n 8.4 K/uL\n [image002.jpg]\n 07:51 PM\n 07:57 PM\n 04:11 AM\n 06:16 AM\n 08:17 AM\n WBC\n 11.7\n 13.4\n 8.4\n Hct\n 27.9\n 29.0\n 31.0\n Plt\n 94\n 100\n 107\n Cr\n 0.8\n 0.9\n 0.9\n TC02\n 26\n 23\n Glucose\n 100\n 106\n 105\n Other labs: PT / PTT / INR:20.7/45.5/2.0, CK / CKMB / Troponin-T:197//,\n ALT / AST:66/110, Alk Phos / T Bili:165/5.7, Differential-Neuts:76.2 %,\n Lymph:10.5 %, Mono:11.8 %, Eos:0.8 %, Lactic Acid:2.8 mmol/L,\n Albumin:2.6 g/dL, LDH:389 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:3.0\n mg/dL\n Fluid analysis / Other labs: NH3: pending\n Imaging: CXR :\n Head CT : pending\n Chest CT ; pending\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy,\n will look for intracranial bleed (esp with significant respi alkalosis)\n with head CT vs progressive hepatic encephalopathy vs seizure (unclear\n why he would seize unless alkalosis has caused him to do so).\n - PS ventilation for now\n - avoid sedation\n - Head and Chest CT\n Neurology consult if head CT negative for bleed and EEG not revealing\n for seizure\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS:\n - Cont lactulose after placement of OG\n - Head CT and Chest CT to look for bleed and source of infection.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - neurology consult\n - EEG\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO/ lactulose\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Comments:\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: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2147-10-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 423266, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 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: Oral\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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / 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: large spont. TVs\n Assessment of breathing comfort: No response (sleeping / sedated)\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: Adjust Min. ventilation to control pH; Comments:\n respiratory alkalosis\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 08:30\n Bedside Procedures:\n Comments:\n Pt remains intubated for airway protection. Plan is for MRI head to\n eval neuro status.\n" }, { "category": "Physician ", "chartdate": "2147-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 423479, "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 URINE CULTURE - At 08:18 AM\n EEG - At 02:46 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n > Markedly improved mental status\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 07:58 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 (98.5\n HR: 118 (96 - 141) bpm\n BP: 125/74(90) {92/52(66) - 139/85(101)} mmHg\n RR: 10 (10 - 18) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 75.3 kg (admission): 75.3 kg\n Height: 67 Inch\n Bladder pressure: 11 (11 - 11) mmHg\n Total In:\n 1,588 mL\n 180 mL\n PO:\n TF:\n IVF:\n 948 mL\n 80 mL\n Blood products:\n Total out:\n 835 mL\n 985 mL\n Urine:\n 835 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 753 mL\n -806 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 1,026 (850 - 1,070) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 29\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.43/30/431/18/-2\n Ve: 7.7 L/min\n PaO2 / FiO2: 1,078\n Physical Examination\n General Appearance: No acute distress, Thin, icteric\n Eyes / Conjunctiva: PERRL\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 Abdominal: Soft, Non-tender, Bowel sounds present, Distended, large\n ascites\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x2, Movement: Purposeful, not able to move the\n right leg and increasd patellar reflex on the right. Downgoing toes\n bilateral,\n Labs / Radiology\n 10.0 g/dL\n 123 K/uL\n 131 mg/dL\n 0.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 31.6 %\n 12.2 K/uL\n [image002.jpg]\n 04:11 AM\n 06:16 AM\n 08:17 AM\n 11:51 AM\n 12:53 PM\n 04:50 PM\n 07:04 PM\n 09:35 PM\n 05:54 AM\n 06:04 AM\n WBC\n 13.4\n 8.4\n 10.9\n 12.2\n Hct\n 29.0\n 31.0\n 28.9\n 31.6\n Plt\n 100\n 107\n 114\n 123\n Cr\n 0.9\n 0.9\n 0.9\n 0.8\n TropT\n <0.01\n TCO2\n 23\n 24\n 25\n 25\n 22\n 21\n Glucose\n 106\n 105\n 107\n 131\n Other labs: PT / PTT / INR:21.2/44.0/2.0, CK / CKMB /\n Troponin-T:158/6/<0.01, ALT / AST:59/106, Alk Phos / T Bili:136/6.2,\n Differential-Neuts:81.8 %, Lymph:7.3 %, Mono:9.9 %, Eos:0.9 %, Lactic\n Acid:2.8 mmol/L, Albumin:2.5 g/dL, LDH:434 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n CXR : improved lung volumes compared to . no obvious\n infiltrate.\n Sputum : GPR and GPC in pairs and chains\n Assessment and Plan\n 41 yo male with cirrhosis (EtOH/HCV) and hepatic encephalopathy found\n down on the floor with pool of saliva intubated for mental status now\n improved, without clear explanation for why he declined.\n > Respiratory failure: unclear etiology to his decline in mental\n status. There was no clear precipitating event: infection, bleed (Hct\n stable), cardiac event (nl ECG) or addition of new sedating\n medications. At baseline he likely has impaired respiratory function\n from his ascites which causes a functional restrictive vent deficit.\n His acute decline could represent a worsening of his encephalopathy\n (NH3 286) evidence of head bleed on CT or seizure on EEG. Marked\n improvement in mental status after starting lactulose. Extubated\n . Sputum culture is likely to be oral flora base on appearance\n of CXR and clinical improvement, will defer treatment\n - Pulmonary toilet, HOB elevation\n - cont lactulose as below\n HEPATIC ENCEPHALOPATHY / ALTERED MENTAL STATUS: no evidence of head\n bleed or seizure. Markedly improved with lactulose. Notably EEG did\n not reveal seizure. There is no clear precipitant for his decline other\n then worsening hepatic encephalopathy. He is markedly improved this\n morning.\n - Cont lactulose and rifax (will likely need an NG tube)\n - Restart lasix and spironolactone\n - need a repeat paracentesis in the near future will confer with\n liver service.\n - Avoid sedation\n - Cont Cipro for SBP prophylaxis\n - Vitamin K for 3 day\n - F/ read of the MRI\n > Right leg weakness: Neuro team concerned for right leg weakness, will\n f/u MRI/A (no evidence of acute process) still with decreased right leg\n . Appreciate neurology input: he still has some right lower leg\n weakness\n > Thrombocytopenia: likely underlying cirrhosis and sequestration.\n > Pulmonary Hyptertension: likely underlying liver disease\n (?hepatopulmonary syndrome). The current presentation is not consistent\n with decompensated pulm hypertension. Can cont the sildenafil for now\n and restart illoprost when more awake.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: PO when able\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:45 AM\n 18 Gauge - 08:03 AM\n Prophylaxis:\n DVT: Boots, INR 2.0\n Stress ulcer: PPI\n VAP: HOB elevation, Aspiration precautions.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-10-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 422907, "text": "41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and\n hepatitis C on transplant list, hypothyroidism who presents with\n altered mental status. The day prior to presentation, the patient was\n complaining of feeling sick and nauseated. He vomited several times but\n did take all of his medications per his mother as she gives them to\n him. She went to check on him the morning of presentation and he was\n unresponsive and gagging on emesis. She called EMS. At the OSH, he was\n intubated for airway protection. CXR was negative for infiltrate, u/a\n was clean and CT of the head was negative for an acute process.\n Events;Extubated at 2230\n Altered mental status /ESLD secondary to alcohol and hep C\n Assessment:\n Extubated at 2230 was not on any sedation,lethargic oriented to self\n and place,denies any pain,anxious and calling out for\n mother,MAE,afebrile,tachycardic 120-130,Ascitis ^^ liver enzymes\n Action:\n Pt was successfully extubated,on 40% FM weaned off now on\n RA, LS clear/diminished sats upto 95%.In hepatic encephalopathy-hold\n sedating medications, mental status slowly improving,denies any pain pt\n was anxious after extubation,called his mother and left the\n message,may visit later during the day. On rifaximine and lactulose\n for ESLD,lactulose regular diose and Q2H prn given no BM so far\n Response:\n Pt slowly improving on MS\n :\n Clear liquids started- Continue lactulose,hold sedatimg meds,f/u\n cultures,paracentesis,call out to floor if remains stable.\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427072, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt initially on RA when awake, once sleeping and his prior history of\n OSA placed on cpap machine, dropped to 92% when sleeping until placed\n on CPAP\n Action:\n Sats greater than 95%\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Abdomen firmly distended with bowel sounds hypoactive. Pt initially\n pleasantly confused then increasingly agitated and eventually combative\n and aggressive, requiring 4 point soft restraints and haldol IVP. Pt\n would not take PO lactulose and unable to get a flexiseal to give PR\n dose of lactulose. Pt starting to stool. At 0330 pt more responsive\n and agitation decreased, took 60mL PO dose of laculose and stooling\n began, more responsive and not combative, restraints removed. Pts INR\n 2.5 given 1 unit of FFP.\n Action:\n 1 unit FFP, Lactulose, haldol IV, removed restraints\n Response:\n Pt more responsive, less combative, oriented to surroundings, stooling\n moderate/large amounts of loose green stool\n Plan:\n c\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427169, "text": "41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Got Haldol 2.5mg IV twice which did calm\n him down. Started passing stools and MS improved.\n Hepatic \n Assessment:\n Oriented X 3 but yet was very agitated and disoriented overnight,\n passing liquid stool thru flexi seal, taking po lactulose, hct 21.0\n Action:\n Transfusing 1 unit PBC\ns, guiac positive stool, flexi seal inserted due\n to large amounts of liquid stool\n Response:\n Remains oriented X3, monitoring stool. IPost transfusion Hct this\n afternoon. Post transfusion Hct 24, Pt,ptt inr decreased.\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427167, "text": "HPI:\n 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Got Haldol 2.5mg IV twice which did calm\n him down. Started passing stools and MS improved.\n Hepatic \n Assessment:\n Oriented X 3 but yet was very agitated and disoriented overnight,\n passing liquid stool thru flexi seal, taking po lactulose, hct 21.0\n Action:\n Transfusing 1 unit PBC\ns, guiac positive stool, flexi seal inserted due\n to large amounts of liquid stool\n Response:\n Remains oriented X3, monitoring stool. IPost transfusion Hct this\n afternoon.\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs\n" }, { "category": "Physician ", "chartdate": "2147-11-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 425268, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - CT: no SBO, + ascites\n - hepatology - do not tap unless painful\n - abd px disappeared after 1800 cc stool output\n - levothyroxin & cipro changed back to PO\n - Iloprost started\n - Needs sleep study\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 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 06:18 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: 103 (85 - 113) bpm\n BP: 101/49(61) {88/37(50) - 136/72(84)} mmHg\n RR: 14 (10 - 19) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.6 kg (admission): 78.6 kg\n Total In:\n 2,590 mL\n 240 mL\n PO:\n 1,990 mL\n 240 mL\n TF:\n IVF:\n 600 mL\n Blood products:\n Total out:\n 3,670 mL\n 180 mL\n Urine:\n 1,070 mL\n 180 mL\n NG:\n Stool:\n 2,600 mL\n Drains:\n Balance:\n -1,080 mL\n 60 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: intubated\n Eyes / Conjunctiva: PERRL, Pupils dilated, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\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), (Breath Sounds: Crackles :\n at the bases), course breath sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended but soft.\n Extremities: Right: Absent, Left: Absent\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 105 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 98 mEq/L\n 122 mEq/L\n 27.9 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TCO2\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: Resolved. Likely secondary to severe constipation.\n After drinking contrast patient had large volume stool output. CT scan\n preliminarily no SBO, but ascities present. Abdominal pain now\n resolved after BMs.\n - follow-up final CT abd/pelvis read\n # Recurrent altered mental status: Mental status currently at\n baseline. Unclear why the patient continues to have these episodes of\n AMS that resolve quickly. Per report he had been taking his lactulose\n on the floor prior to intubation. No evidence for infections, stroke\n or intracranial hemorrhage. Hyponatremia is stable and patient is\n currently mentating at baseline so likely not the explanation. The\n patient could have a sleep disorder, though maintained his O2 sats\n throughout the night on telemetry monitoring. Possible alkalosis\n evidence for this thus far.\n -Lactulose with goal of BMs/day + rifaximine for hepatic\n encephalopathy prevention\n -for hyponatremia- see below\n -sleep disorder- ABG this am for baseline. Needs sleep study.\n Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # Hyponatremia: Stable in the low 120s. Has been in the low 130s\n previously on this admission. Patient got increased volume yesterday\n secondary to drinking PO contrast.\n - decrease fluid restriction to 1.2L\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n -follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Low Na diet. Fluid restriction 1.2L. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Dispo: c/o to - service.\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:29 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": "2147-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426598, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Peritoneal fluid with GPCs --> coag negative staph, likely contaminant\n Unable to get iloprost.\n Viagra resumed\n Diuretics resumed\n On CPAP overnight\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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 08:06 AM\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: 35.6\nC (96\n HR: 93 (78 - 116) bpm\n BP: 111/56(69) {90/54(61) - 126/82(89)} mmHg\n RR: 19 (10 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,100 mL\n 270 mL\n PO:\n 1,010 mL\n 270 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,025 mL\n 255 mL\n Urine:\n 1,025 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n 15 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\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 91 K/uL\n 8.8 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426797, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Continued on lasix and spironolactone po\n On CPAP overnight\n Currently feeling well, no complaints. Sleeping well on CPAP.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:54 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress. Sitting up in\n chair.\n Eyes / Conjunctiva: PERRL, icteric sclera.\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: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n (unchanged)\n Extremities: trace edema bilaterally.\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 91 K/uL\n 8.8 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo M with pulmonary hypertension, ESLD on transplant list with Hep C\n cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with his\n fourth episode of altered mental status requiring intubation for airway\n protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x4 on floor. DDX: hepatic encephalopathy,\n OSA or other sleep disordered breathing.\n - lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n - possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions. Plan right now to continue CPAP at\n night with late night or overnight lactulose; if requires repeat\n intubation with this regimen, will likely need trach.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb\n losses. Continue to follow daily.\n .\n # Staph coag neg in ascitic fluid. ?contaminant. From tap , did\n not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection. Likely contaminant, not treating. If fever or\n abdominal pain, will need repeat tap.\n .\n # Hyponatremia: Significantly improved. With this improvement and\n slight bump in creatinine, will liberalize to 2 L restriction.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -lasix and spironolactone, can further titrate on the floor.\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue sildenifil and iloprost (restarted over weekend).\n ICU Care\n Nutrition:\n Comments: regular low Na low protein\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 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:transfer to floor today.\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426656, "text": "Hepatic encephalopathy ESLD: Hep C and alcohol cirrhosis\n Assessment:\n Alert oriented x3. ^ mobility steady gait bed to chair. Abd lg firm\n distended ascites increased , + BS, Passing loose stool golden stool\n s/p lactalose.\n Action:\n Received lactulose, rifaximin and flagyl per routine.\n Response:\n Improved encephalopathy, passing > 4loose stool\n Plan:\n Cont lactulose goal >4BM/day, rifaximin, and po flagyl\n Cont lactalose and spironolactone\n continue prophylactic cipro (SBP).\n follow up hepatology recommendations.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Alert oriented x3, Na 135, Foley icteric u/o 25-50cc/hr\n Action:\n Low Na+ diet, continue 1 l fluid restriction, received lasix and\n aldactone\n Response:\n Following fluid restriction, Marginal icteric u/o despite diuretics\n Plan:\n Monitor Na+ , maintain Fluid restriction to 1 liter/24hrs.\n Obstructive sleep apnea (OSA)\n Assessment:\n RR 18-24 reg nonlabored, Lungs clear dim dases, Sats 97-100% R/A\n Action:\n HOB maintained >30 degrees.\n Response:\n Stable resp status.\n Plan:\n continue nighttime BIPAP\n" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426805, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:35 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, icteric\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.8 g/dL\n 91 K/uL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intubation each time, currently\n he is back to baseline and has tolerated his CPAP well over the weekend\n with no episodes of morning altered MS\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We deferred trach\n to give a trial of CPAP which he has done well..\n - supportive CPAP at night.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen, added back the diuretic regimen\n - consider Vit K trial if INR remains elevated.\n >Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with SIADH\n >Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland (by cell count) although growing coag neg staph. c.\n dif was neg\n >Low HCO3: likely the lactulose regimen, he has stabilized the\n values for now. Will cont to follow.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 426812, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n On RA sats 100% A&OX3, MAE, oob to chair and ambulates to commode\n independently, ADLs performed with minimal assist.\n Action:\n Assess for changes in mental status and oxygenation\n Response:\n Pt remains A&OX3 requiring no supplemental oxygen\n Plan:\n Continue to assess need for supplementary oxygen, utilize CPAP/BIPAP\n during night\n Hepatic encephalopathy\n Assessment:\n A&OX3, denies pain and nausea. Stooling med-lg amounts X3 this shift.\n Action:\n Lactulose given\n Response:\n Continues to report feeling\nfine\n. Stooling /d as ordered\n Plan:\n Transfer to 10, increase activity as tolerated\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n On fluid restriction, increased to 2000cc/24h\n Action:\n Rationing fluid in small portions to assure that pt can consume fluid\n throughout the day\n Response:\n Pt complaining and relentlessly asking for more fluids. Understands\n fluid restriction, requires lots of emotional support from staff.\n Plan:\n Maintain strict fluid restriction of 2000cc/d, provide emotional\n support\n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 426814, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further\n management; pt will stay in MICU 7 for bs, auto-set at HS for ? OSA,\n ongoing discussion of possible trach d/t apneic episodes\n Obstructive sleep apnea (OSA)\n Assessment:\n On RA sats 100% A&OX3, MAE, oob to chair and ambulates to commode\n independently, ADLs performed with minimal assist.\n Action:\n Assess for changes in mental status and oxygenation\n Response:\n Pt remains A&OX3 requiring no supplemental oxygen\n Plan:\n Continue to assess need for supplementary oxygen, utilize CPAP/BIPAP\n during night\n Hepatic encephalopathy\n Assessment:\n A&OX3, denies pain and nausea. Stooling med-lg amounts X3 this shift.\n Action:\n Lactulose given\n Response:\n Continues to report feeling\nfine\n. Stooling /d as ordered\n Plan:\n Transfer to 10, increase activity as tolerated\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n On fluid restriction, increased to 2000cc/24h\n Action:\n Rationing fluid in small portions to assure that pt can consume fluid\n throughout the day\n Response:\n Pt complaining and relentlessly asking for more fluids. Understands\n fluid restriction, requires lots of emotional support from staff.\n Plan:\n Maintain strict fluid restriction of 2000cc/d, provide emotional\n support\n Foley discontinued @ 12:30, pt dtv @ 8:30- pt has been made aware. 40mf\n PO lasix given @ 12\n" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426767, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:35 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, icteric\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.8 g/dL\n 91 K/uL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426769, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n Continued on lasix and spironolactone po\n On CPAP overnight\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:54 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\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: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 91 K/uL\n 8.8 g/dL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo M with pulmonary hypertension, ESLD on transplant list with Hep C\n cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with his\n fourth episode of altered mental status requiring intubation for airway\n protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x4 on floor. DDX: hepatic encephalopathy,\n OSA or other sleep disordered breathing.\n - lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n - possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n lasix and spironolactone\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold sildenifil; restart iloprost..\n ICU Care\n Nutrition:\n Comments: regular low Na low protein\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 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" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426790, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:35 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, icteric\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.8 g/dL\n 91 K/uL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline and has tolerated his CPAP well over the\n weekend.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We deferred trach\n to give a trial of CPAP which he has done well..\n - supportive CPAP at night.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen, added back the diuretic regimen\n - consider Vit K trial if INR remains elevated.\n >Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with SIADH\n >Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland (by cell count) although growing coag neg staph. c.\n dif was neg\n >Low HCO3: likely the lactulose regimen, he has stabilized the\n values for now. Will cont to follow.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426649, "text": "possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n Hepatic encephalopathy ESLD: Hep C and alcohol cirrhosis\n Assessment:\n Action:\n lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n Response:\n Plan:\n lactulose, rifaximin, flagyl as above.\n -restart diuretics\n lasix and spironolactone\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426650, "text": "possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n Hepatic encephalopathy ESLD: Hep C and alcohol cirrhosis\n Assessment:\n Action:\n lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n Response:\n Plan:\n lactulose, rifaximin, flagyl as above.\n -restart diuretics\n lasix and spironolactone\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Low Na+ diet, continue 1 l fluid restriction, Lasix restarted, U/O\n overnight 50-25 cc/hr\n Response:\n Following fluid restriction. Little effect from lasix. No treatment for\n decreased U/O\n Plan:\n Monitor Na+ and intake. Monitor diuresis, I+O\n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426752, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt has been maintaining good O2 sats on RA while awake\n Action:\n Pt placed on Bipap for 4hrs to sleep\n Response:\n O2 sats cont to be >97%\n Plan:\n Cont to follow O2 sats and mental status during the day shift\n Hepatic encephalopathy\n Assessment:\n Pt has cont to be A&Ox3, very cooperative, cooperative and assisting\n with his ADL\n Action:\n Titrated Lactulose to stools daily,\n Response:\n Pt cont to be A&O x3 and able to MAE and get self to commode with some\n assist\n Plan:\n Will cont to follow stool amts , titrate lactolse and eval MS for\n changes , use Bipap at night\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt cont with a marginal u/o but is maintaining Bp and NA is increasing\n Action:\n Fluid restriction\n Response:\n Awaiting labs results\n Plan:\n Cont to follow and support NA as indicated\n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426754, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further\n management; pt will stay in MICU 7 for bs, auto-set at HS for ? OSA,\n ongoing discussion of possible trach d/t apneic episodes\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has been maintaining good O2 sats on RA while awake\n Action:\n Pt placed on Bipap for 4hrs to sleep\n Response:\n O2 sats cont to be >97%\n Plan:\n Cont to follow O2 sats and mental status during the day shift\n Hepatic encephalopathy\n Assessment:\n Pt has cont to be A&Ox3, very cooperative, cooperative and assisting\n with his ADL\n Action:\n Titrated Lactulose to stools daily,\n Response:\n Pt cont to be A&O x3 and able to MAE and get self to commode with some\n assist\n Plan:\n Will cont to follow stool amts , titrate lactolse and eval MS for\n changes , use Bipap at night\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt cont with a marginal u/o but is maintaining Bp and NA is increasing\n Action:\n Fluid restriction\n Response:\n Awaiting labs results\n Plan:\n Cont to follow and support NA as indicated\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426404, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Denies abdominal pain\n Action:\n Monitored\n Response:\n Plan:\n Monitor abd pain\n Knowledge Deficit\n Assessment:\n Oriented x 3, calm and pleasant. asks questions. Often states you\n should ask my mother she would know.anxious at times\n Action:\n Questions reinforced, reassuarance offered.\n Response:\n Calms with reassurance\n Plan:\n Offer reassurance , encourage verbalization.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Regular diet to be change to low na. continue 1 l fluid restriction\n Response:\n Following fluid restriction\n Plan:\n Monitor na and intake.\n Hepatic encephalopathy\n Assessment:\n alert\n Action:\n Monitor , lactulose\n Response:\n Has not stooled this shift\n Plan:\n Monitor mental status, bowel movements, continue Lactulose, monitor\n mental status\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Restart meds\n Response:\n Plan:\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats\n Response:\n O2 sat 93%\n Plan:\n Monitor respiratory status, 02 sats, niv mask ventilation at night as\n per orders.\n" }, { "category": "Physician ", "chartdate": "2147-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 426406, "text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:00 AM\n - Extubated successfully.\n - Ongoing discussion re: trach, may get next week. Nighttime PPV until\n then.\n - CPAP overnight, tolerated well\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 02:11 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 08:04 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: 92 (92 - 119) bpm\n BP: 121/62(74) {99/51(65) - 151/96(100)} mmHg\n RR: 15 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 2,120 mL\n 90 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,150 mL\n Blood products:\n Total out:\n 1,264 mL\n 330 mL\n Urine:\n 964 mL\n 330 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 856 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 936) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///16/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: No acute distress, sitting up in chair.\n Eyes / Conjunctiva: PERRL, icteric sclera.\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal) SM at LSB.\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: (Breath Sounds: Clear : ), diminished at bases.\n Abdominal: Soft, Non-tender, Distended (unchanged)\n Extremities: Right: 1+, Left: 1+ edema\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): place, month, year , appropriate, slightly\n slowed speech (unchanged)\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 16 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 107 mEq/L\n 130 mEq/L\n 25.1 %\n 10.0 K/uL\n [image002.jpg]\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n 10.0\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n Plt\n 123\n 92\n 86\n 86\n 77\n Cr\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n TCO2\n 20\n 18\n 17\n Glucose\n 105\n 107\n 113\n 129\n 103\n 110\n 99\n Other labs: PT / PTT / INR:24.4/49.5/2.4, ALT / AST:59/102, Alk Phos /\n T Bili:126/7.1, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:349 IU/L, Ca++:8.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x 4 on floor. Differential has included\n hepatic encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing. episodes have all\n occurred within a few hours of 8am meds (no lactulose for at least \n hours).\n - lactulose TID to maintain 4+ BM/day, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n continue nighttime CPAP (tolerating well thus\n far).\n - Discussion continues re: possible trach. Would clearly be\n beneficial if this process is due to obstructive apnea (though unclear\n if this is the cause). Would also be beneficial if central apnea in\n that could easily be hooked up to vent (but weighing risks, ?need to go\n to vent facility following discharge, increased risk of\n infections/VAPs) as opposed to repeated intubations and potential\n hypoxic exposures. Will continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n .\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued on floor due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold sildenifil; restart iloprost..\n ICU Care\n Nutrition:\n Comments: regular, will change to low Na\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:10 AM\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:ICU\n" }, { "category": "Physician ", "chartdate": "2147-11-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 427295, "text": "Chief Complaint: Encephalopathy\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 41 yo man with Hep C cirrhosis. Admitted for encephalopathy. O\n 24 Hour Events:\n ULTRASOUND - At 08:21 AM\n ultrasound of the liver\n BLOOD CULTURED - At 10:00 PM\n #1 right hand\n BLOOD CULTURED - At 10:30 PM\n #2 left hand\n PARACENTESIS - At 11:34 PM\n WOUND CULTURE - At 12:31 AM\n paracentesis fluid sent for culture\n CALLED OUT\n Febrile overnight, had paracentesis performed.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n lactulose\n protonix\n synthroid\n cipro\n rifaxamin\n illoprost\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 10:56 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 (98.8\n HR: 76 (76 - 121) bpm\n BP: 107/57(69) {89/48(60) - 122/76(86)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 3,252 mL\n 790 mL\n PO:\n 1,860 mL\n 790 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 1,142 mL\n Total out:\n 1,785 mL\n 3,100 mL\n Urine:\n 1,385 mL\n 550 mL\n NG:\n Stool:\n Drains:\n 2,250 mL\n Balance:\n 1,467 mL\n -2,310 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 99%\n ABG: ///18/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, icteric sclerae\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time., Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 55 K/uL\n 100 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 21 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.2 %\n 6.3 K/uL\n [image002.jpg]\n 04:00 AM\n 03:54 AM\n 06:00 AM\n 08:45 AM\n 12:06 AM\n 05:01 AM\n 07:43 AM\n 03:22 PM\n 08:25 PM\n 03:52 AM\n WBC\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n 5.6\n 6.3\n Hct\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n 21.4\n 21.0\n 24.9\n 24.3\n 22.2\n Plt\n 86\n 77\n 91\n 85\n 74\n 66\n 55\n Cr\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n 1.5\n 1.2\n 1.0\n Glucose\n 110\n 99\n 108\n 143\n 118\n 118\n 118\n 100\n Other labs: PT / PTT / INR:25.1/53.2/2.5, ALT / AST:43/69, Alk Phos / T\n Bili:113/5.9, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:3.9 g/dL, LDH:225 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.2\n mg/dL\n Fluid analysis / Other labs: U/S with normal portal flow.\n Acites: WBC 149, 4 polys, 63 lymphs\n Imaging: CXR: \n Microbiology: C. diff negative\n Assessment and Plan\n Hep C Cirrhosis: MS much better today.\n Anemia: Hct is still trending down. unclear cause. Follow Hct and\n guaiac stools.\n Pulmonary HTN: Sildenafil on hold, continue iloprost\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 AM\n 20 Gauge - 04:45 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 426826, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further\n management; pt will stay in MICU 7 for bs, auto-set at HS for ? OSA,\n ongoing discussion of possible trach d/t apneic episodes\n Obstructive sleep apnea (OSA)\n Assessment:\n On RA sats 100% A&OX3, MAE, oob to chair and ambulates to commode\n independently, ADLs performed with minimal assist.\n Action:\n Assess for changes in mental status and oxygenation\n Response:\n Pt remains A&OX3 requiring no supplemental oxygen\n Plan:\n Continue to assess need for supplementary oxygen, utilize CPAP/BIPAP\n during night. Team assesses unresponsive periods to Obstructive Sleep\n Apnea\n Hepatic encephalopathy\n Assessment:\n A&OX3, denies pain and nausea. Stooling med-lg amounts X3 this shift.\n Action:\n Lactulose given\n Response:\n Continues to report feeling\nfine\n. Stooling /d as ordered\n Plan:\n Transfer to 10, increase activity as tolerated, jhold lactulose\n for stools\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n On fluid restriction, increased to 2000cc/24h\n Action:\n Rationing fluid in small portions to assure that pt can consume fluid\n throughout the day\n Response:\n Pt complaining and relentlessly asking for more fluids. Understands\n fluid restriction, requires lots of emotional support from staff.\n Plan:\n Maintain strict fluid restriction of 2000cc/d, provide emotional\n support\n Foley discontinued @ 12:30, pt voided @ 1600\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 65 kg\n Daily weight:\n 64.4 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; osteoporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:67\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None, CPAP mask\n O2 saturation:\n 100% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 480 mL\n 24h total out:\n 318 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 08:45 AM\n Potassium:\n 3.7 mEq/L\n 08:45 AM\n Chloride:\n 109 mEq/L\n 08:45 AM\n CO2:\n 17 mEq/L\n 08:45 AM\n BUN:\n 25 mg/dL\n 08:45 AM\n Creatinine:\n 1.2 mg/dL\n 08:45 AM\n Glucose:\n 143 mg/dL\n 08:45 AM\n Hematocrit:\n 26.1 %\n 08:45 AM\n Finger Stick Glucose:\n 140\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Credit Cards: none\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: MICU 7\n Transferred to: 10\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2147-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 426827, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further\n management; pt will stay in MICU 7 for bs, auto-set at HS for ? OSA,\n ongoing discussion of possible trach d/t apneic episodes\n Obstructive sleep apnea (OSA)\n Assessment:\n On RA sats 100% A&OX3, MAE, oob to chair and ambulates to commode\n independently, ADLs performed with minimal assist.\n Action:\n Assess for changes in mental status and oxygenation\n Response:\n Pt remains A&OX3 requiring no supplemental oxygen\n Plan:\n Continue to assess need for supplementary oxygen, utilize CPAP/BIPAP\n during night. Team assesses unresponsive periods to Obstructive Sleep\n Apnea\n Hepatic encephalopathy\n Assessment:\n A&OX3, denies pain and nausea. Stooling med-lg amounts X3 this shift.\n Action:\n Lactulose given\n Response:\n Continues to report feeling\nfine\n. Stooling /d as ordered\n Plan:\n Transfer to 10, increase activity as tolerated, jhold lactulose\n for stools\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n On fluid restriction, increased to 2000cc/24h\n Action:\n Rationing fluid in small portions to assure that pt can consume fluid\n throughout the day\n Response:\n Pt complaining and relentlessly asking for more fluids. Understands\n fluid restriction, requires lots of emotional support from staff.\n Plan:\n Maintain strict fluid restriction of 2000cc/d, provide emotional\n support\n Foley discontinued @ 12:30, pt voided @ 1600\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 65 kg\n Daily weight:\n 64.4 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; osteoporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:67\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None, CPAP mask\n O2 saturation:\n 100% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 480 mL\n 24h total out:\n 318 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 08:45 AM\n Potassium:\n 3.7 mEq/L\n 08:45 AM\n Chloride:\n 109 mEq/L\n 08:45 AM\n CO2:\n 17 mEq/L\n 08:45 AM\n BUN:\n 25 mg/dL\n 08:45 AM\n Creatinine:\n 1.2 mg/dL\n 08:45 AM\n Glucose:\n 143 mg/dL\n 08:45 AM\n Hematocrit:\n 26.1 %\n 08:45 AM\n Finger Stick Glucose:\n 140\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Credit Cards: none\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: MICU 7\n Transferred to: 10\n Date & time of Transfer: \n ------ Protected Section ------\n Phlebitis in R arm antecub. IV discontinued due to purulent drainage at\n the site. Tunneling at insertion, team aware, no interventions at this\n time\n ------ Protected Section Addendum Entered By: , RN\n on: 16:08 ------\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427101, "text": "Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427104, "text": "HPI:\n 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Got Haldol 2.5mg IV twice which did calm\n him down. Started passing stools and MS improved.\n Hepatic \n Assessment:\n Oriented X 3 but yet was very agitated and disoriented overnight,\n passing liquid stool thru flexi seal, taking po lactulose, hct 21.0\n Action:\n Transfusing 1 unit PBC\ns, guiac positive stool, flexi seal inserted due\n to large amounts of liquid stool\n Response:\n Remains oriented X3, monitoring stool. IPost transfusion Hct this\n afternoon.\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs\n" }, { "category": "Nursing", "chartdate": "2147-11-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427300, "text": "HPI:\n 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Started passing stools and MS improved.\n Currently pleasant, oriented x3 and cooperative with care.\n Hepatic \n Assessment:\n Oriented X 3, passing liquid stool thru flexi seal, taking po\n lactulose, hct 24.0 Febrile o/n.\n Action:\n Received 1 unit red cells yesterday. Hct remains 24. Flexiseal\n discontinued d/t bothersome for pt and pt is able to get OOB to\n commode. Cultured overnight\n Response:\n Remains oriented X3, monitoring stool..\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs\n" }, { "category": "Nursing", "chartdate": "2147-11-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427301, "text": "HPI:\n 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Started passing stools and MS improved.\n Currently pleasant, oriented x3 and cooperative with care.\n Hepatic \n Assessment:\n Oriented X 3, passing liquid stool thru flexi seal, taking po\n lactulose, hct 24.0 Febrile o/n.\n Action:\n Received 1 unit red cells yesterday. Hct remains 24. Flexiseal\n discontinued d/t bothersome for pt and pt is able to get OOB to\n commode. Pan cultured overnight. Paracentesis overnoc\n Response:\n Remains oriented X3, monitoring stool..\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs. Provide comfort and support.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n \n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 65 kg\n Daily weight:\n 65.9 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Precautions: No Additional Precautions\n PMH: Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C and ETOH cirrhosis, ascitis, edema, SBP,\n grade I varices; Pulm HTN; hypothyroidism; anxiety; osteoporosis\n hip/spine\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:58\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n CPAP mask\n O2 saturation:\n 95% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 790 mL\n 24h total out:\n 3,180 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:52 AM\n Potassium:\n 3.8 mEq/L\n 03:52 AM\n Chloride:\n 116 mEq/L\n 03:52 AM\n CO2:\n 18 mEq/L\n 03:52 AM\n BUN:\n 21 mg/dL\n 03:52 AM\n Creatinine:\n 1.0 mg/dL\n 03:52 AM\n Glucose:\n 100 mg/dL\n 03:52 AM\n Hematocrit:\n 24.0 %\n 11:01 AM\n Finger Stick Glucose:\n 152\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: 1024\n Transferred to: SICU A\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2147-11-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 427305, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 08:21 AM\n ultrasound of the liver\n BLOOD CULTURED - At 10:00 PM\n #1 right hand\n BLOOD CULTURED - At 10:30 PM\n #2 left hand\n PARACENTESIS - At 11:34 PM\n WOUND CULTURE - At 12:31 AM\n paracentesis fluid sent for culture\n guiac + so did not call out\n received 1 unit PRBCs & 2units FFP prior to paracentesis\n D/c'd viagra per liver transplant (agitation)\n febrile/tachycardic-> Dx tap no SBP\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:46 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: 37.6\nC (99.7\n HR: 105 (70 - 121) bpm\n BP: 117/62(75) {89/40(51) - 121/76(86)} mmHg\n RR: 11 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 3,252 mL\n 390 mL\n PO:\n 1,860 mL\n 390 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 1,142 mL\n Total out:\n 1,785 mL\n 2,810 mL\n Urine:\n 1,385 mL\n 410 mL\n NG:\n Stool:\n Drains:\n 2,250 mL\n Balance:\n 1,467 mL\n -2,420 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 99%\n ABG: ///18/\n Physical Examination\n gen: A& O x 3\n heent: icteric sclera, EOMI, PERRL\n neck: supple, no LAD\n pulm: CTAB anteriorly\n cv:RRR s1 s2 no mrg\n abd: distended, soft, non tender, umbilical hernia distended, BS+\n extr: no pedal edema, dp's palpable bilaterally\n Labs / Radiology\n 55 K/uL\n 7.6 g/dL\n 100 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 21 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.2 %\n 6.3 K/uL\n [image002.jpg]\n 04:00 AM\n 03:54 AM\n 06:00 AM\n 08:45 AM\n 12:06 AM\n 05:01 AM\n 07:43 AM\n 03:22 PM\n 08:25 PM\n 03:52 AM\n WBC\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n 5.6\n 6.3\n Hct\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n 21.4\n 21.0\n 24.9\n 24.3\n 22.2\n Plt\n 86\n 77\n 91\n 85\n 74\n 66\n 55\n Cr\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n 1.5\n 1.2\n 1.0\n Glucose\n 110\n 99\n 108\n 143\n 118\n 118\n 118\n 100\n Other labs: PT / PTT / INR:25.1/53.2/2.5, , Ca++:8.6 mg/dL, Mg++:2.0\n mg/dL, PO4:2.2 mg/dL\n Ascites fluid: glucose 128, albumin <1.0, WBC 149 (4 polys, 63 L, 8 M,\n 15 Meso, 10 mac), 897 RBCs, gram stain\n no microbes\n Stool: C. diff neg.\n Assessment and Plan\n Mr. is a 41 yo male with ESLD, pulm HTN, originally admitted\n with AMS now with multiple MICU transfers and intubations for\n unresponsiveness, now re-transferred to MICU for altered mental\n status.\n .\n #Altered Mental Status: most likely hepatic encephalopathy. He had\n a RUQ ultrasound that showed normal hepatic blood flow and a large\n amount of abdominal ascities. His mental status had cleared by\n yesterday morning after he began having BMs again and has remained\n clear since. His renal function also improved to his baseline. He was\n continued on PO lactulose and maintained a good stool output. He had a\n fever of 100.7 yesterday and a diagnostic paracentesis with no evidence\n of SBP. He was pan-cultured. His fever spontaneously defervesced.\n - cont. PO lactulose and monitor BMs\n - cont. CPAP at night\n - f/u urine, stool, blood, and ascities fluid cultures\n -haldol 2.5-5mg IV for agitation/combativeness\n .\n #Agitation/combativeness\n Currently resolved, likely exacerbation\n of hepatic encephalopathy\n - sildenafil stopped per hepatology recs\n -haldol prn\n -restraints as needed for aggression toward staff\n -work up of encephalopathy as above\n .\n #Coagulopathy - likely ESLD and poor nutrition, PTT >150 which may\n be due to heparin sq injections given very minimal SQ tissue. Patient\n was given 2 units of FFP prior to diagnostic paracentesis yesterday.\n -daily coags in am\n -ffp if needed for bleeding/NGT placement\n .\n #Acute Renal Failure: Resolved.\n .\n # ESLD: ETOH/HepC, +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list.\n - continue lactulose/rifaximin as above.\n - guaic stools\n - lasix and spironolactone d/c'd arf\n - continue cipro for sbp prophylaxis\n -bilit/coags/plt generally stable\n -monitor tbili, lft's\n .\n # pulmonary HTN: pt breathing comfortably on RA presently.\n - continue iloprost\n - sildenafil stopped per hepatology recs\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Patient was\n transfused 1 unit pRBCs yesterday for hct drop to 21. Increased to 24\n post transfusion, but now back down to 22. Stools are not frankly\n bloody but are guiaic positive. Likely slow GI ooze. PLT's also down\n to 55.\n - trend HCT -tid.\n - pantoprazole increased to Q12H.\n .\n # hypothyroidism: dose recently increased persistently elevated\n TSH.\n - continue levothyroxine at 88mcg/qdaily.\n # FEN: low sodium diet, 2L fluid restriction.\n # Access: PIVs\n # Code: Full code\n # Dispo: To - service.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 AM\n 20 Gauge - 04:45 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": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426645, "text": "Somnolence and respiratory failure. Respiratory code and intubation\n for airway protection now x4 on floor. DDX: hepatic encephalopathy,\n OSA or other sleep disordered breathing.\n - lactulose TID to maintain 4+ BM/day, rifaximin and flagyl-\n - possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n .\n # Metabolic acidosis. may be in part compensatory for respiratory\n alkalosis (hyperventilatory with liver failure and ascites), but bicarb\n dropping throughout this admission, likely an effect of increasing\n lactulose requirements leading to worsening diarrhea and bicarb losses.\n .\n # Gram positive cocci in ascitic fluid. ?contaminant. From tap ,\n did not grow until . 70 WBCs with 7% PMNs, not consistent with\n SBP/infection.\n - consider re-tap of ascites.\n - f/u cultures, hold off on vanco for now.\n .\n # Hyponatremia: 1 L fluid restriction. Restart diuretics.\n .\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -restart diuretics\n lasix and spironolactone\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n" }, { "category": "Physician ", "chartdate": "2147-11-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 427083, "text": "Chief Complaint: delerium/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 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confuse. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Got Haldol 2.5mg IV twice which did calm\n him down. Started passing stools and MS improved.\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 02:35 AM\n Other medications:\n lactulose\n sildenafil\n protonix\n hep s/q\n synthoid\n cipro\n rifaxamin\n iloprost\n Changes to medical and family history:\n PMHX:\n Grade I varices\n Hep C, ETOH abuse in past, currently on transplant list.\n Hypothyroidism\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 Gastrointestinal: No(t) Abdominal pain\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 70 (70 - 114) bpm\n BP: 98/54(65) {86/40(52) - 116/80(84)} mmHg\n RR: 8 (8 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.2 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 519 mL\n PO:\n 60 mL\n TF:\n IVF:\n Blood products:\n 459 mL\n Total out:\n 0 mL\n 590 mL\n Urine:\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: No(t) Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, umbilical hernia\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, and time, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.2 g/dL\n 66 K/uL\n 118 mg/dL\n 1.5 mg/dL\n 17 mEq/L\n 3.3 mEq/L\n 27 mg/dL\n 112 mEq/L\n 142 mEq/L\n 21.0 %\n 5.6 K/uL\n [image002.jpg]\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n 08:45 AM\n 12:06 AM\n 05:01 AM\n 07:43 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n 5.6\n Hct\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n 21.4\n 21.0\n Plt\n 92\n 86\n 86\n 77\n 91\n 85\n 74\n 66\n Cr\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n 1.5\n TCO2\n 17\n Glucose\n 129\n 103\n 110\n 99\n 108\n 143\n 118\n 118\n Other labs: PT / PTT / INR:23.5/122.6/2.3, ALT / AST:43/69, Alk Phos /\n T Bili:113/5.9, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:3.9 g/dL, LDH:225 IU/L, Ca++:8.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Fluid analysis / Other labs: Ascites fluid with low WBC, cx with\n coag neg staph that has not been treated.\n Assessment and Plan\n HEPATIC : Much improved today, now oriented and calm.\n Continue lactulose. Could have been precipitated by bleed or\n hypovolemia.\n Anemia: Hct has dropped, but not having melena. Transfused 1U.\n Monitor for GIB.\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: F/U on US results.\n PULMONARY HYPERTENSION (PULM HTN, PHTN): On sildenafil and iloprost\n Acute Renal Failure: Increased creatinine over past two days. be\n somewhat dry. Recently started aldactone and lasix. Hold diuretics.\n Coagulopathy: Unclear why PTT increased, ?effect of s/q heparin. Will\n stop.\n OSA: On CPAP\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2147-11-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 427290, "text": "HPI:\n 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confused. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Started passing stools and MS improved.\n Currently pleasant, oriented x3 and cooperative with care.\n Hepatic \n Assessment:\n Oriented X 3, passing liquid stool thru flexi seal, taking po\n lactulose, hct 24.0 Febrile o/n.\n Action:\n Received 1 unit red cells yesterday. Hct remains 24. Flexiseal\n discontinued d/t bothersome for pt and pt is able to get OOB to\n commode. Cultured overnight\n Response:\n Remains oriented X3, monitoring stool..\n Plan:\n If patient refuses lactulose let team know, continue to monitor neuro\n status. Follow up with HCt\ns and labs\n" }, { "category": "Nursing", "chartdate": "2147-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427080, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt initially on RA when awake, once sleeping and his prior history of\n OSA placed on cpap machine, dropped to 92% when sleeping until placed\n on CPAP, lung sounds clear bilaterally\n Action:\n Sats greater than 95%\n Response:\n Pt tolerating CPAP well, oxygenating well\n Plan:\n Continue to monitor patient\ns respiratory status\n Hepatic encephalopathy\n Assessment:\n Abdomen firmly distended with bowel sounds hypoactive, increasingly\n firm throughout the night. Pt initially pleasantly confused then\n increasingly agitated and eventually combative and aggressive,\n requiring 4 point soft restraints and haldol IVP. Pt would not take PO\n lactulose and unable to get a flexiseal to give PR dose of lactulose.\n Pt starting to stool. At 0330 pt more responsive and agitation\n decreased, took 60mL PO dose of laculose and stooling increasing. Pts\n INR 2.5 given, Hct dropping,\n Action:\n 1 unit FFP, Lactulose, haldol IV, removed restraints, albumin 50g\n (200mL)\n Response:\n Pt more responsive, less combative, oriented to surroundings, stooling\n moderate/large amounts of loose green stool\n Plan:\n Liver Ultrasound (keep NPO until after), paracentesis ?, monitor Hct at\n 0800 ? transfusion\n" }, { "category": "Nursing", "chartdate": "2147-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427273, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt initially on 2L NC when awake, once sleeping and his prior history\n of OSA placed on cpap machine, dropped to 92% when sleeping until\n placed on CPAP, lung sounds clear bilaterally, no cough noted, awake\n and oriented x 3\n Action:\n Sats greater than 96% on both 2L and CPAP\n Response:\n Pt tolerating CPAP well, oxygenating well, mentating appropriately.\n Plan:\n Continue to monitor patient\ns respiratory status\n Hepatic encephalopathy\n Assessment:\n Abdomen firmly distended with bowel sounds hypoactive, increasingly\n firm throughout the night with dullness upon percussion. Pt awake and\n oriented x 3, MAE and appropriate throughout the night. Pt taking PO\n lactulose and flexiseal draining green liquid stool, oozing around\n flexiseal onto pink pad. Skin on bilateral gluteals noted to be\n excoriated/reddened. Post paracentesis pt abd softly distended. Pts\n INR 2.5. Tmax 100.7.\n Action:\n 1 unit FFP, Lactulose, paracentesis, specimen sent to lab for\n culture/cell count, Blood cultures x 2.\n Response:\n Pt responsive & oriented to surroundings, stooling moderate/large\n amounts of loose green stool, abdomen less distended and more soft,\n Tcurrent of 99.7 PO without intervention besides environmental control.\n Plan:\n Continue to monitor, continue with stooling and lactulose, monitor\n labs, awaiting pending cultures.\n" }, { "category": "Physician ", "chartdate": "2147-11-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 427265, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 08:21 AM\n ultrasound of the liver\n BLOOD CULTURED - At 10:00 PM\n #1 right hand\n BLOOD CULTURED - At 10:30 PM\n #2 left hand\n PARACENTESIS - At 11:34 PM\n WOUND CULTURE - At 12:31 AM\n paracentesis fluid sent for culture\n guiac + so did not call out\n D/c'd viagra per liver transplant (agitation)\n febrile/tachycardic-> Dx tap no SBP\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 06:46 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: 37.6\nC (99.7\n HR: 105 (70 - 121) bpm\n BP: 117/62(75) {89/40(51) - 121/76(86)} mmHg\n RR: 11 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 65.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 3,252 mL\n 390 mL\n PO:\n 1,860 mL\n 390 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 1,142 mL\n Total out:\n 1,785 mL\n 2,810 mL\n Urine:\n 1,385 mL\n 410 mL\n NG:\n Stool:\n Drains:\n 2,250 mL\n Balance:\n 1,467 mL\n -2,420 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 99%\n ABG: ///18/\n Physical Examination\n gen: Awake and alert, oriented to person, repeatedly answers\n \"wednesday\" to other orientation questions\n heent: icteric sclera, EOMI, PERRL\n neck: supple, no LAD\n pulm: CTAB anteriorly\n cv:RRR s1 s2 no mrg\n abd: distended, non tender, umbilical hernia distended no compressible,\n BS+\n extr: no pedal edema, dp's palpable bilaterally\n Labs / Radiology\n 55 K/uL\n 7.6 g/dL\n 100 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 21 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.2 %\n 6.3 K/uL\n [image002.jpg]\n 04:00 AM\n 03:54 AM\n 06:00 AM\n 08:45 AM\n 12:06 AM\n 05:01 AM\n 07:43 AM\n 03:22 PM\n 08:25 PM\n 03:52 AM\n WBC\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n 5.6\n 6.3\n Hct\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n 21.4\n 21.0\n 24.9\n 24.3\n 22.2\n Plt\n 86\n 77\n 91\n 85\n 74\n 66\n 55\n Cr\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n 1.5\n 1.2\n 1.0\n Glucose\n 110\n 99\n 108\n 143\n 118\n 118\n 118\n 100\n Other labs: PT / PTT / INR:25.1/53.2/2.5, ALT / AST:43/69, Alk Phos / T\n Bili:113/5.9, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:3.9 g/dL, LDH:225 IU/L, Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.2\n mg/dL\n Assessment and Plan\n Mr. is a 41 yo male with ESLD, pulm HTN, originally admitted\n with AMS now with multiple MICU transfers and intubations for\n unresponsiveness, now re-transferred to MICU for altered mental\n status.\n .\n #Altered Mental Status: most likely hepatic encephalopathy and poor\n response to po lactulse. Does have recent episode of partial sbo/ileus\n which resolved on its own, which may be contributing in this case. He\n did have worsened renal function this morning somewhat concerning for\n possible development of HRS although may have been due to dehydration.\n Worsened renal function could also be responsible for worsened mental\n status. Other possiblility is GI bleed given HCT drop to 23, which\n could also precipitate encephalopathy. Infection also possible, with\n most likely source being SBP however he has had several para's neg for\n SBP based on cell count/diff however, culture from positive for\n coag neg staph. Portal vein thrombosis is also a consideration.\n -PR lactulose if able although have been unable agitation\n -continue with po lactulose 45ml QID and 2 am dose to prevent early\n morning unresponsiveness (have not been able to give since arrival in\n ICU agitation and combativeness)\n -CPAP overnight which has helped prevent early am unresponsiveness\n during recent ICU stay\n -consider repeat para in am if no improvement\n -Abd u/s in the AM to eval for portal vein thrombosis\n -consider empiric abx for SBP if unable to tap in the AM, would cover\n for coag neg staph given ascites fluid culture w/coag neg staph from\n , although thought likely to be a contaminant.\n -haldol 2.5-5mg IV for agitation/combativeness\n .\n #Agitation/combativeness\n likely exacerbation of hepatic\n encephalopathy\n -haldol prn\n -restraints as needed for aggression toward staff\n -work up of encephalopathy as above\n .\n #Coagulopathy - likely ESLD and poor nutrition, PTT >150 which may\n be due to heparin sq injections given very minimal SQ tissue\n -repeat coags in am\n -ffp if needed for bleeding/NGT placement\n .\n #Acute Renal Failure: creatinine elevated this am up to 1.6 this\n morning, thought by the team dehydration as diuretics recently\n started. Diuretics held this am and he was given albumin.\n -f/u creatine\n -albumin/IVF prn\n -send UA and culture\n .\n # ESLD: ETOH/HepC, +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list.\n - continue lactulose/rifaximin as above.\n - guaic stools\n - lasix and spironolactone d/c'd arf\n - continue cipro for sbp prophylaxis\n -bilit/coags/hct/plt generally stable\n -monitor tbili, lft's\n .\n # pulmonary HTN: pt breathing comfortably on RA presently.\n - continue iloprost\n - continue sildenafil.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Currently HCT\n somewhat lower than usual at 23,slightly concerning for possibility of\n GI ooze. PLT's have been stable.\n - guaic stools.\n - trend HCT.\n .\n # hypothyroidism: dose recently increased persistently elevated\n TSH.\n - continue levothyroxine at 88mcg/qdaily.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 AM\n 20 Gauge - 04:45 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": "2147-11-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 425886, "text": "Chief Complaint: Altered Mental status\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 41 year old male who is well known to MICU green service with hx of\n cirrhossis Hep C and EtOH with mulipte admissions to the ICU in the\n setting of altered mental status now admitted after being found with\n diminished responsiveness on the floor this morning. He was not noted\n to have any seizure activity, he was not hypercarbic on ABG. He was\n intubated for an inability to defend his airway. There was a question\n of a nose bleed for which an NG tube was placed which did not reveal\n blood in the stomach\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies\n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a mean\n pressure of 8. Notably he had a pulmonary capillary wedge pressure of\n approximately 15 at that time and his cardiac output was normal with\n 6.7 liters per minute, cardiac index of 3.7. His pulmonary vascular\n resistance was nearly normal at 251 and he was in sinus rhyth at that\n time with a heart rate of 90\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n ? Sleep disordered breathing: had sleep study which was non diagnostics\n Occupation: lives with mom\n Drugs: remote IVD\n Tobacco: quit \n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 90) bpm\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n RR: 19 (14 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: icteric\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended and fluid\n filled by exam in the lower quads.\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: no clonus. + gag, corneal, pupils. No increased DTR\n / Radiology\n 123 K/uL\n 30\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 07:19 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other : PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: ET in good position, NG ion good position. No infiltrate\n or effusion, improved volumes when compared to prior film\n Assessment and Plan\n 41 yo male with hx of HepC /EtOH cirrhosis admitted with altered mental\n status and inability to defend airway. This is consistent with prior\n admissions to the ICU in the setting of decompensated encephalopathy,\n notably these events tedn to be noticed in the early morning hours.\n Recently he had a sleep study which although not diagnostic in\n quality(he did not achieve REM sleep) seemed to suggest that there was\n an element of sleep disordered breathing.\n HEPATIC ENCEPHALOPATHY / Altered mental status: this is the third\n admission to the ICU this month for altered MS \n picture. Concerning findings on this admission include a suggestion of\n gaze deviation. I am concerned for both a head bleed (given his\n coagulopathy) and sub-clinical status. This is similar to his previous\n admission both in exam and timing of the event. For now it seems\n reasonable to trial him on lactulose and see if we can get improvement.\n If there is no improvement in his exam we can investigate via head CT\n and/or EEG. He likely has some element of sleep disordered breathing\n and I think he would benefit from CPAP at night. Additional components\n include metabolic (hyponatremia). There does not appear to be an\n infectious component.\n - Defer head CT and EEG for now\n - regimen as below for encephalopathy\n - SBP prophylaxis with cipro\n > Respiratory alkaosis: we have seen this in his past admission and it\n was thought to be both ascites, liver dysfunction and potentially\n exacerbated by central causes. We will cont to follow for now.\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY): chronic and related to his\n liver failure and diuresis. Will defer additional diuresis and follow\n Na closely\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: would cont previous regimen of\n lactulose, rifaximin and flagyl. There was a question of a nose bleed\n that did not appear related to a GI bleed (hct stable, neg OG return),\n will d/w liver.\n > Pulmonary hypertension: holding treatment for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:47 AM\n Comments:\n Prophylaxis:\n DVT: Boots, holding hep sq in the setting of\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 Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 425887, "text": "Chief Complaint: Altered Mental status\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 41 year old male who is well known to MICU green service with hx of\n cirrhossis Hep C and EtOH with mulipte admissions to the ICU in the\n setting of altered mental status now admitted after being found with\n diminished responsiveness on the floor this morning. He was not noted\n to have any seizure activity, he was not hypercarbic on ABG. He was\n intubated for an inability to defend his airway. There was a question\n of a nose bleed for which an NG tube was placed which did not reveal\n blood in the stomach\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies\n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a mean\n pressure of 8. Notably he had a pulmonary capillary wedge pressure of\n approximately 15 at that time and his cardiac output was normal with\n 6.7 liters per minute, cardiac index of 3.7. His pulmonary vascular\n resistance was nearly normal at 251 and he was in sinus rhyth at that\n time with a heart rate of 90\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n ? Sleep disordered breathing: had sleep study which was non diagnostics\n Occupation: lives with mom\n Drugs: remote IVD\n Tobacco: quit \n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 90) bpm\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n RR: 19 (14 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: icteric\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended and fluid\n filled by exam in the lower quads.\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: no clonus. + gag, corneal, pupils. No increased DTR\n / Radiology\n 123 K/uL\n 30\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 07:19 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other : PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: ET in good position, NG ion good position. No infiltrate\n or effusion, improved volumes when compared to prior film\n Assessment and Plan\n 41 yo male with hx of HepC /EtOH cirrhosis admitted with altered mental\n status and inability to defend airway. This is consistent with prior\n admissions to the ICU in the setting of decompensated encephalopathy,\n notably these events tedn to be noticed in the early morning hours.\n Recently he had a sleep study which although not diagnostic in\n quality(he did not achieve REM sleep) seemed to suggest that there was\n an element of sleep disordered breathing.\n HEPATIC ENCEPHALOPATHY / Altered mental status: this is the third\n admission to the ICU this month for altered MS \n picture. Concerning findings on this admission include a suggestion of\n gaze deviation. I am concerned for both a head bleed (given his\n coagulopathy) and sub-clinical status. This is similar to his previous\n admission both in exam and timing of the event. For now it seems\n reasonable to trial him on lactulose and see if we can get improvement.\n If there is no improvement in his exam we can investigate via head CT\n and/or EEG. He likely has some element of sleep disordered breathing\n and I think he would benefit from CPAP at night. Additional components\n include metabolic (hyponatremia). There does not appear to be an\n infectious component. For now we will cont PS ventilation until his MS\n improves.\n - Defer head CT and EEG for now\n - regimen as below for encephalopathy\n - SBP prophylaxis with cipro\n > Respiratory alkaosis: we have seen this in his past admission and it\n was thought to be both ascites, liver dysfunction and potentially\n exacerbated by central causes. We will cont to follow for now.\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY): chronic and related to his\n liver failure and diuresis. Will defer additional diuresis and follow\n Na closely\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: would cont previous regimen of\n lactulose, rifaximin and flagyl. There was a question of a nose bleed\n that did not appear related to a GI bleed (hct stable, neg OG return),\n will d/w liver.\n > Pulmonary hypertension: holding treatment for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Defer tube feeds for now\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:47 AM\n Comments:\n Prophylaxis:\n DVT: Boots, holding hep sq in the setting of\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 Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 425888, "text": "Chief Complaint: Altered Mental status\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 41 year old male who is well known to MICU green service with hx of\n cirrhossis Hep C and EtOH with mulipte admissions to the ICU in the\n setting of altered mental status now admitted after being found with\n diminished responsiveness on the floor this morning. He was not noted\n to have any seizure activity, he was not hypercarbic on ABG. He was\n intubated for an inability to defend his airway. There was a question\n of a nose bleed for which an NG tube was placed which did not reveal\n blood in the stomach\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies\n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a mean\n pressure of 8. Notably he had a pulmonary capillary wedge pressure of\n approximately 15 at that time and his cardiac output was normal with\n 6.7 liters per minute, cardiac index of 3.7. His pulmonary vascular\n resistance was nearly normal at 251 and he was in sinus rhyth at that\n time with a heart rate of 90\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n ? Sleep disordered breathing: had sleep study which was non diagnostics\n Occupation: lives with mom\n Drugs: remote IVD\n Tobacco: quit \n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 90) bpm\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n RR: 19 (14 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: icteric\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended and fluid\n filled by exam in the lower quads.\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: no clonus. + gag, corneal, pupils. No increased DTR\n / Radiology\n 123 K/uL\n 30\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 07:19 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other : PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: ET in good position, NG ion good position. No infiltrate\n or effusion, improved volumes when compared to prior film\n Assessment and Plan\n 41 yo male with hx of HepC /EtOH cirrhosis admitted with altered mental\n status and inability to defend airway. This is consistent with prior\n admissions to the ICU in the setting of decompensated encephalopathy,\n notably these events tedn to be noticed in the early morning hours.\n Recently he had a sleep study which although not diagnostic in\n quality(he did not achieve REM sleep) seemed to suggest that there was\n an element of sleep disordered breathing.\n HEPATIC ENCEPHALOPATHY / Altered mental status: this is the third\n admission to the ICU this month for altered MS \n picture. Concerning findings on this admission include a suggestion of\n gaze deviation. I am concerned for both a head bleed (given his\n coagulopathy) and sub-clinical status. This is similar to his previous\n admission both in exam and timing of the event. For now it seems\n reasonable to trial him on lactulose and see if we can get improvement.\n If there is no improvement in his exam we can investigate via head CT\n and/or EEG. He likely has some element of sleep disordered breathing\n and I think he would benefit from CPAP at night. Additional components\n include metabolic (hyponatremia). There does not appear to be an\n infectious component. For now we will cont PS ventilation until his MS\n improves.\n - Defer head CT and EEG for now\n - regimen as below for encephalopathy\n - SBP prophylaxis with cipro\n > Respiratory alkaosis: we have seen this in his past admission and it\n was thought to be both ascites, liver dysfunction and potentially\n exacerbated by central causes. We will cont to follow for now.\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY): chronic and related to his\n liver failure and diuresis. Will defer additional diuresis and follow\n Na closely\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: would cont previous regimen of\n lactulose, rifaximin and flagyl. There was a question of a nose bleed\n that did not appear related to a GI bleed (hct stable, neg OG return),\n will d/w liver.\n > Pulmonary hypertension: holding treatment for now.\n Other issues per ICU resident note.\n ICU Care\n Nutrition:\n Defer tube feeds for now\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:47 AM\n Comments:\n Prophylaxis:\n DVT: Boots, holding hep sq in the setting of\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 Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425891, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at 250 TID.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking slightly toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion. R leg with increased\n tone/difficulty relaxing.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now (iloprost can\n resume once extubated).\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition: NPO for now, TFs if prolonged intubation. Fluid restrict\n once taking PO\n Glycemic Control: Regular insulin sliding scale if needed.\n Lines: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\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": "2147-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427227, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt initially on 2L NC when awake, once sleeping and his prior history\n of OSA placed on cpap machine, dropped to 92% when sleeping until\n placed on CPAP, lung sounds clear bilaterally, no cough noted, awake\n and oriented x 3\n Action:\n Sats greater than 96% on both 2L and CPAP\n Response:\n Pt tolerating CPAP well, oxygenating well, mentating appropriately.\n Plan:\n Continue to monitor patient\ns respiratory status\n Hepatic encephalopathy\n Assessment:\n Abdomen firmly distended with bowel sounds hypoactive, increasingly\n firm throughout the night with dullness upon percussion. Pt awake and\n oriented x 3, MAE and appropriate throughout the night. Pt taking PO\n lactulose and flexiseal draining green liquid stool, oozing around\n flexiseal onto pink pad. Skin on bilateral gluteals noted to be\n excoriated/reddened. Post paracentesis pt abd softly distended. Pts\n INR 2.5. Tmax 100.7.\n Action:\n 1 unit FFP, Lactulose, paracentesis, specimen sent to lab for\n culture/cell count, Blood cultures x 2.\n Response:\n Pt responsive & oriented to surroundings, stooling moderate/large\n amounts of loose green stool, abdomen less distended and more soft,\n Tcurrent of 99.7 PO without intervention besides environmental control.\n Plan:\n Continue to monitor, continue with stooling and lactulose, monitor\n labs, awaiting pending cultures.\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425900, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at 250 TID.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking slightly toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion. R leg with increased\n tone/difficulty relaxing.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n CXR: ETT ~1.8 cm\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition: NPO for now, TFs if prolonged intubation. Fluid restrict\n once taking PO\n Glycemic Control: Regular insulin sliding scale if needed.\n Lines: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\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": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425971, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight (not wearing\n at time of event).\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at 250 TID.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender. Mostly tympanitic with\n peripheral dullness. L para site dressed. Linear healing scab on\n abdomen.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking slightly toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion. R leg with ?increased\n tone/difficulty relaxing.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Peritoneal fluid ()\n 70 WBCs (7% polys), no growth.\n CXR: ETT ~1.8 cm above carina, OGT in place. Improved lung volumes.\n No focal infiltrate or pulmonary edema.\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition: NPO for now, TFs if prolonged intubation. Fluid restrict\n once taking PO\n Glycemic Control: Regular insulin sliding scale if needed.\n Lines: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\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 ------ Protected Section ------\n Pt seen and examined. Given that the patient had to be intubated 4\n times for respiratory failure and there is a high likelihood of this\n happening again I will discuss with the family the possibility of a\n percutaneous tracheostomy tube placement.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:02 ------\n" }, { "category": "Nursing", "chartdate": "2147-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 427226, "text": "Obstructive sleep apnea (OSA)\n Assessment:\n Pt initially on RA when awake, once sleeping and his prior history of\n OSA placed on cpap machine, dropped to 92% when sleeping until placed\n on CPAP, lung sounds clear bilaterally\n Action:\n Sats greater than 95%\n Response:\n Pt tolerating CPAP well, oxygenating well\n Plan:\n Continue to monitor patient\ns respiratory status\n Hepatic encephalopathy\n Assessment:\n Abdomen firmly distended with bowel sounds hypoactive, increasingly\n firm throughout the night. Pt initially pleasantly confused then\n increasingly agitated and eventually combative and aggressive,\n requiring 4 point soft restraints and haldol IVP. Pt would not take PO\n lactulose and unable to get a flexiseal to give PR dose of lactulose.\n Pt starting to stool. At 0330 pt more responsive and agitation\n decreased, took 60mL PO dose of laculose and stooling increasing. Pts\n INR 2.5 given, Hct dropping,\n Action:\n 1 unit FFP, Lactulose, haldol IV, removed restraints, albumin 50g\n (200mL)\n Response:\n Pt more responsive, less combative, oriented to surroundings, stooling\n moderate/large amounts of loose green stool\n Plan:\n Liver Ultrasound (keep NPO until after), paracentesis ?, monitor Hct at\n 0800 ? transfusion\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425863, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed and\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 2. MED Rifaximin 400 mg PO TID\n 3. MED Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n 4. MED Heparin 5000 UNIT SC TID\n 5. MED Iloprost *NF* 2.5 mcg Inhalation q2h while awake\n * Patient Taking Own Meds *\n 6. MED Lactulose 60 mL PO Q2H:PRN\n titrate to bowel movements per day.\n 7. MED Lactulose 60 mL PO TID\n titrate to bowel movements per day\n 8. MED Ciprofloxacin HCl 250 mg PO Q24H\n 9. MED Levothyroxine Sodium 88 mcg PO DAILY\n 10. MED MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n 11. MED Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses\n 12. MED Furosemide 40 mg PO DAILY Start: In am\n Hold for SBP < 100.\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n Cardiovascular: (S1: No(t) 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 Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: Resolved. Likely secondary to severe constipation.\n After drinking contrast patient had large volume stool output. CT scan\n preliminarily no SBO, but ascities present. Abdominal pain now\n resolved after BMs.\n - follow-up final CT abd/pelvis read\n # Recurrent altered mental status: Mental status currently at\n baseline. Unclear why the patient continues to have these episodes of\n AMS that resolve quickly. Per report he had been taking his lactulose\n on the floor prior to intubation. No evidence for infections, stroke\n or intracranial hemorrhage. Hyponatremia is stable and patient is\n currently mentating at baseline so likely not the explanation. The\n patient could have a sleep disorder, though maintained his O2 sats\n throughout the night on telemetry monitoring. Possible alkalosis\n evidence for this thus far.\n -Lactulose with goal of BMs/day + rifaximine for hepatic\n encephalopathy prevention\n -for hyponatremia- see below\n -sleep disorder- ABG this am for baseline. Needs sleep study.\n Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # Hyponatremia: Stable in the low 120s. Has been in the low 130s\n previously on this admission. Patient got increased volume yesterday\n secondary to drinking PO contrast.\n - decrease fluid restriction to 1.2L\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n - follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Low Na diet. Fluid restriction 1.2L. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Dispo: c/o to - service.\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\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": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 425865, "text": "Chief Complaint: Altered Mental status\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 41 year old male who is well known to MICU green service with hx of\n cirrhossis Hep C and EtOH with mulipte admissions to the ICU in the\n setting of altered mental status now admitted after being found with\n diminished responsiveness on the floor this morning. He was not noted\n to have any seizure activity, he was not hypercarbic on ABG. He was\n intubated for an inability to defend his airway.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\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 - HCV and EtOH Cirrhosis with ascites and edema, biopsy\n diagnosed in , last vl 32,600 copies\n - h/o SBP early on cipro prophylaxis\n - Grade I esophageal varices\n - Pulmonary HTN: s/p cath on demonstrating the\n following: moderate elevation of his pulmonary arterial\n pressures with an initial pressure of 57/22 with a mean of 36.\n His right venticular pressures were 57/19 and his right atrial\n pressures were elevated an A-wave of 21, V-wave of 11, and a\n mean pressure of 8. Notably he had a pulmonary capillary wedge\n pressure of approximately 15 at that time and his cardiac output\n was normal with 6.7 liters per minute, cardiac index of 3.7. His\n pulmonary vascular resistance was nearly normal at 251 and he\n was in sinus rhyth at that time with a heart rate of 90\n - Hypothyroidism\n - Anxiety disorder\n - h/o EtOH abuse, IVDU\n - osteoperosis of hip and spine per pt\n Occupation: lives with mom\n Drugs: remote IVD\n Tobacco: quit \n Alcohol: remote\n Other:\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 81 (81 - 90) bpm\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n RR: 19 (14 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 7.6 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: icteric\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Increased, clonus\n Labs / Radiology\n 123 K/uL\n 30\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 10.6 K/uL\n [image002.jpg]\n 09:34 AM\n 12:56 PM\n 09:18 PM\n 03:19 AM\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 07:19 AM\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR\n Assessment and Plan\n 41 yo male with hx of HepC /EtOH cirrhosis admitted with altered mental\n status and inability to defend airway. This is consistent with prior\n admissions to the ICU in the setting of decompensated encephalopathy,\n notably these events tedn to be noticed in the early morning hours.\n Recently he had a sleep study which although not diagnostic in\n quality(he did not achieve REM sleep) seemed to suggest that there was\n an element of sleep disordered breathing.\n HEPATIC ENCEPHALOPATHY\n HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:47 AM\n Comments:\n Prophylaxis:\n DVT: Boots\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 Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425872, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons and code blue called. Patient intubated for airway\n protection. Maintained O2 sats >90 and never lost pulse, SBPs in\n 100s-110s. ABG prior to intubation (?prior to bagging) 7.50/22/87.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at low dose.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n Cardiovascular: (S1: No(t) 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 Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: Resolved. Likely secondary to severe constipation.\n After drinking contrast patient had large volume stool output. CT scan\n preliminarily no SBO, but ascities present. Abdominal pain now\n resolved after BMs.\n - follow-up final CT abd/pelvis read\n # Recurrent altered mental status: Mental status currently at\n baseline. Unclear why the patient continues to have these episodes of\n AMS that resolve quickly. Per report he had been taking his lactulose\n on the floor prior to intubation. No evidence for infections, stroke\n or intracranial hemorrhage. Hyponatremia is stable and patient is\n currently mentating at baseline so likely not the explanation. The\n patient could have a sleep disorder, though maintained his O2 sats\n throughout the night on telemetry monitoring. Possible alkalosis\n evidence for this thus far.\n -Lactulose with goal of BMs/day + rifaximine for hepatic\n encephalopathy prevention\n -for hyponatremia- see below\n -sleep disorder- ABG this am for baseline. Needs sleep study.\n Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # Hyponatremia: Stable in the low 120s. Has been in the low 130s\n previously on this admission. Patient got increased volume yesterday\n secondary to drinking PO contrast.\n - decrease fluid restriction to 1.2L\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n - follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Low Na diet. Fluid restriction 1.2L. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Dispo: c/o to - service.\n # Code: full\n # communication: mother\n ICU \n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\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": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425874, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons and code blue called. Patient intubated for airway\n protection. Maintained O2 sats >90 and never lost pulse, SBPs in\n 100s-110s. ABG prior to intubation (?prior to bagging) 7.50/22/87.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at low dose.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his third episode of altered mental status requiring intubation for\n airway protection.\n # Abdominal pain: Resolved. Likely secondary to severe constipation.\n After drinking contrast patient had large volume stool output. CT scan\n preliminarily no SBO, but ascities present. Abdominal pain now\n resolved after BMs.\n - follow-up final CT abd/pelvis read\n # Recurrent altered mental status: Mental status currently at\n baseline. Unclear why the patient continues to have these episodes of\n AMS that resolve quickly. Per report he had been taking his lactulose\n on the floor prior to intubation. No evidence for infections, stroke\n or intracranial hemorrhage. Hyponatremia is stable and patient is\n currently mentating at baseline so likely not the explanation. The\n patient could have a sleep disorder, though maintained his O2 sats\n throughout the night on telemetry monitoring. Possible alkalosis\n evidence for this thus far.\n -Lactulose with goal of BMs/day + rifaximine for hepatic\n encephalopathy prevention\n -for hyponatremia- see below\n -sleep disorder- ABG this am for baseline. Needs sleep study.\n Consider auto titrating CPAP.\n -infection- unlikely but could consider diagnostic para if not\n improving. Two diagnostic this admission were negative\n # Hyponatremia: Stable in the low 120s. Has been in the low 130s\n previously on this admission. Patient got increased volume yesterday\n secondary to drinking PO contrast.\n - decrease fluid restriction to 1.2L\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximine\n -hold diuretics\n -continue ppx cipro for SBP\n - follow up hepatology recs\n # Pulmonary HTN: continue sildenafil and iloprost.\n # Hypothyroidism: continue levothyroxine\n # FEN: Low Na diet. Fluid restriction 1.2L. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Dispo: c/o to - service.\n # Code: full\n # communication: mother\n ICU \n Nutrition: NPO for now, TFs if prolonged intubation.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\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": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425879, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at low dose.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect.\n - hepatic encephalopathy - lactulose Q2-4 to start, continue\n rifaximin and flagyl\n - Possible OSA\n - Management of hyponatremia\n - Infectious workup\n - Tox screens\n # Respiratory alkalosis.\n # Hyponatremia: Stable in the low 120s. Has been in the low 130s\n previously on this admission. Patient got increased volume yesterday\n secondary to drinking PO contrast.\n - decrease fluid restriction to 1.2L\n # ESLD: Hep C and alcohol cirrhosis.\n -continue lactulose as above, continue rifaximin\n -holding diuretics for now\n -continue prophylactic cipro (SBP)\n - follow up hepatology recs\n # Pulmonary HTN: continue iloprost; sildenifil held for concern of\n worsening OSA.\n # Hypothyroidism: continue levothyroxine\n # FEN: Low Na diet. Fluid restriction 1.2L. Monitor lytes as above\n # PPX: heparin SQ for DVT ppx, PPI per home reg, bowel reg as above\n # Dispo: c/o to - service.\n # Code: full\n # communication: mother\n ICU \n Nutrition: NPO for now, TFs if prolonged intubation.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\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": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425902, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight.\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at 250 TID.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender. Mostly tympanitic with\n peripheral dullness. L para site dressed. Linear healing scab on\n abdomen.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking slightly toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion. R leg with ?increased\n tone/difficulty relaxing.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Peritoneal fluid ()\n 70 WBCs (7% polys), no growth.\n CXR: ETT ~1.8 cm above carina, OGT in place. Improved lung volumes.\n No focal infiltrate or pulmonary edema.\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition: NPO for now, TFs if prolonged intubation. Fluid restrict\n once taking PO\n Glycemic Control: Regular insulin sliding scale if needed.\n Lines: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\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": "Nutrition", "chartdate": "2147-11-10 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 426215, "text": "Subjective\nTummy pain\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 66\n 68.4 kg\n 69.9 kg ( 08:00 AM)\n d/t fluid\n 24.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4kg\n 10\n N/A\n 68kg\n 100%\n Diagnosis: Encephalopathy\n PMH : ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Food allergies and intolerances: NKFA\n Pertinent medications: Lactulose, rifaximin, flagyl, cipro,\n lansoprazole, others noted.\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 04:00 AM\n BUN\n 22 mg/dL\n 04:00 AM\n Creatinine\n 1.1 mg/dL\n 04:00 AM\n Sodium\n 132 mEq/L\n 04:00 AM\n Potassium\n 4.0 mEq/L\n 04:00 AM\n Chloride\n 105 mEq/L\n 04:00 AM\n TCO2\n 15 mEq/L\n 04:00 AM\n PO2 (arterial)\n 169 mm Hg\n 02:47 PM\n PCO2 (arterial)\n 22 mm Hg\n 02:47 PM\n pH (arterial)\n 7.49 units\n 02:47 PM\n pH (venous)\n 7.41 units\n 04:19 AM\n pH (urine)\n 6.5 units\n 07:31 AM\n CO2 (Calc) arterial\n 17 mEq/L\n 02:47 PM\n Albumin\n 2.8 g/dL\n 04:42 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:00 AM\n Phosphorus\n 3.8 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.16 mmol/L\n 04:19 AM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n ALT\n 82 IU/L\n 09:38 AM\n Alkaline Phosphate\n 180 IU/L\n 09:38 AM\n AST\n 138 IU/L\n 09:38 AM\n Amylase\n 126 IU/L\n 05:50 AM\n Total Bilirubin\n 5.8 mg/dL\n 09:38 AM\n WBC\n 14.7 K/uL\n 04:00 AM\n Hgb\n 8.7 g/dL\n 04:00 AM\n Current diet order / nutrition support: NPO, w/ 1L fluid restriction\n GI: Abd soft/NT/ND/ ascites/ unchanged umbilical hernia\n Assessment of Nutritional Status\n Pt at risk due to:\n Cirrhosis, current medical condition, needs nutrition support,\n protein-calorie malnutrition (temporal wasting and cachetic)\n Estimated Nutritional Needs based on UBW\n Calories:-2176kcals/day (28-32cal/kg)\n Protein: 68-102g/day (1-1.5g/kg)\n Fluid: per team\n Estimation of previous and current intake:\n Inadequate\n Specifics:\n Pt well known to me from previous admits and followed by me at the\n Transplant Center.\n Adm w/ encephalopathy, intubated x4 d/t hypoxia. In and out of the MICU\n for mngt since admit. Team now considering trach possibly. DDx-\n worsenening hepatic encephalopathy, OSA or other sleep disordered\n breathing.\n Extubated this morning, remains NPO. Rec placing post pyloric feeding\n tube to initiate tube feeds to prevent further nutritional decline.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Adv diet to Reg/ low Na\n 2. Place PPFT, once placement confirmed, start w/ FS Nutren\n Pulmonary @10cc/hr and adv to goal of 45cc/hr to provide 1620kcals and\n 73g prot/day.\n 3. No residuals w/ PPFT, monitor tol w/ abd exam and pt\n complaints.\n 4. c/w lyte mngt as you are.\n Will f/u w/ diet adv/po tol and changes to TF Rx as needed.\n Pls pge w/ questions/concerns #\n 16:02\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426219, "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 >improved MS over last 12hr\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:11 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:00 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 07:44 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: 37.8\nC (100.1\n HR: 97 (81 - 126) bpm\n BP: 102/65(71) {100/45(57) - 143/84(95)} mmHg\n RR: 16 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 70 Inch\n Total In:\n 1,589 mL\n 392 mL\n PO:\n TF:\n IVF:\n 1,269 mL\n 222 mL\n Blood products:\n Total out:\n 470 mL\n 269 mL\n Urine:\n 470 mL\n 269 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 123 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): 1,206 (1,089 - 1,530) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 6 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.49/22/169/15/-3\n Ve: 12.7 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: upper airway)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n CXR : ET in good position, no infil or effusion.\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n NPO f\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426220, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 10:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 04:20 PM\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: 119 (93 - 126) bpm\n BP: 151/76(89) {100/45(57) - 151/76(89)} mmHg\n RR: 12 (11 - 20) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,589 mL\n 1,761 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,269 mL\n 1,181 mL\n Blood products:\n Total out:\n 470 mL\n 704 mL\n Urine:\n 470 mL\n 704 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 1,057 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 1,239) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///15/\n Ve: 14.6 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 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 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": "2147-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426221, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Metronidazole - 10:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 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 04:20 PM\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: 119 (93 - 126) bpm\n BP: 151/76(89) {100/45(57) - 151/76(89)} mmHg\n RR: 12 (11 - 20) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 69.9 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,589 mL\n 1,761 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,269 mL\n 1,181 mL\n Blood products:\n Total out:\n 470 mL\n 704 mL\n Urine:\n 470 mL\n 704 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,119 mL\n 1,057 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 936 (936 - 1,239) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 13\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: ///15/\n Ve: 14.6 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 8.7 g/dL\n 86 K/uL\n 110 mg/dL\n 1.1 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 105 mEq/L\n 132 mEq/L\n 25.9 %\n 14.7 K/uL\n [image002.jpg]\n 07:44 PM\n 04:42 AM\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n WBC\n 10.6\n 9.8\n 18.6\n 14.7\n Hct\n 27.9\n 30\n 28.1\n 27.3\n 25.9\n Plt\n 123\n 92\n 86\n 86\n Cr\n 0.8\n 0.8\n 0.9\n 1.0\n 1.0\n 1.1\n TCO2\n 20\n 18\n 17\n Glucose\n 143\n 105\n 107\n 113\n 129\n 103\n 110\n Other labs: PT / PTT / INR:22.6/58.2/2.2, ALT / AST:82/138, Alk Phos /\n T Bili:180/5.8, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.8\n g/dL, LDH:315 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intuabtion each time, currently\n he is back to baseline.\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We are currently\n weighing the merits of tracheostomy in this patient given the number of\n intubations he has had in the past. It may be helpful with ventilation\n in the evening.\n - cont bolus sedation pending outcome of trach discussion\n - PS ventilation as above.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen\n Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with\n Lactate: most likely underlying liver dysfunction, he has had a\n similar oscillating in the past.\n Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland.\n - check c. dif\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 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": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426689, "text": "Hepatic encephalopathy ESLD: Hep C and alcohol cirrhosis\n Assessment:\n Alert oriented x3. ^ mobility steady gait bed to chair. Abd lg firm\n distended ascites increased , + BS, Passing loose stool golden stool\n s/p lactalose.\n Action:\n Received lactulose, rifaximin and flagyl per routine.\n Response:\n Improved encephalopathy, passing > 4loose stool\n Plan:\n Cont lactulose goal >4BM/day, rifaximin, and po flagyl\n Cont lactalose and spironolactone\n continue prophylactic cipro (SBP).\n follow up hepatology recommendations.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Alert oriented x3, Na 135, Foley icteric u/o 25-50cc/hr\n Action:\n Low Na+ diet, continue 1 l fluid restriction, received lasix and\n aldactone\n Response:\n Following fluid restriction, Marginal icteric u/o despite diuretics\n Plan:\n Monitor Na+ , maintain Fluid restriction to 1 liter/24hrs.\n Obstructive sleep apnea (OSA)\n Assessment:\n RR 18-24 reg nonlabored, Lungs clear dim dases, Sats 97-100% R/A\n Action:\n HOB maintained >30 degrees.\n Response:\n Stable resp status.\n Plan:\n continue nighttime BIPAP\n" }, { "category": "Nursing", "chartdate": "2147-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426207, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Significant Events :\n ****** Extubated at 11 00\n hrs electively. Prpofol off.\n ****** On room air since\n 1500 hrs, Satting at high 90\n ***** Sitting up at chair\n comfortably.\n ***** patient is alert,\n oriented X3 , appropriate.\n ***** LR off ,patient able to\n drink & eat .\n ****** Plan to place on CPAP\n at night.\n Inability to protect airway\n Assessment:\n Received On vent PS/50%/. satting at high >95\ns. ABG with resp\n alkalosis. Extubated at 1100 hrs. Was on face tent. Room air since\n 1500 hrs.\n Action:\n Electively extubated at 1100 hrs successfully. Placed on face tent.\n After that. On room air since 1500 hrs.\n Response:\n Satting at high 90\ns on room air. Denied SOB. Sitting up at chair.\n Plan:\n Continue monitoring his resp status. Will place on CPAP at night .\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen firm distended, ascittis. hepatic encephalopathy, LFT\n elevated. & coagulopathic. H/O epistaxis.\n Action:\n lactulose 60 mlTID ( scheduled) Lactulose 60 ml Q2 hr PRN X1 given.\n Up to BSC X1.\n Response:\n Small Loose stool X1. Sitting Up at chair.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care w/\n barrier cream.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high >95\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for thick yellowish secretions in copious to\n moderate amt\ns. MD notified.. Around 0330 hrs, patient is awake and\n appropriate.\n Response:\n Pt. placed on Propofol gtt for sedation.\n Plan:\n Continue monitoring his resp status & Discuss possible trach procedure\n later this am.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened. Bruises at rt upper chhek from Adhesive tape.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n No change at this time.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity. Sitting\n up at chair.\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426507, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Denies abdominal pain,abd firm distended + bowel sounds.\n Action:\n Monitored.\n Response:\n Denies abd pain.\n Plan:\n Monitor abd pain.\n Knowledge Deficit\n Assessment:\n Oriented x 3, pleasant. asks questions. Often states you should ask my\n mother she would know. anxious at times,\n Action:\n Questions answered, reassuarance offered.\n Response:\n Calms with reassurance\n Plan:\n Offer reassurance , encourage verbalization.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Regular diet to be changed to low na. continue 1 l fluid restriction.\n Lasix restarted. Ho notified of uo<30\n Response:\n Following fluid restriction. Litlle effect from lasix. No treatment for\n decreased uo md .\n Plan:\n Monitor na and intake. Monitor diuresis i+0.\n Hepatic encephalopathy\n Assessment:\n Alert,\n Action:\n Monitor , lactulose given\n Response:\n 1 medium loose stool\n Plan:\n Monitor mental status, bowel movements, continue Lactulose,\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Documented pulm htn\n Action:\n Meds reordered, however lioprost unavailable until Tuesday .families\n supply is out and pt pharmacy will not dispense until pt out of\n hospital. Mds aware.\n Response:\n Stable at present\n Plan:\n Administer meds when available, monitor vs. md to order Viagra.\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats\n Response:\n O2 sat 93%\n Plan:\n Monitor respiratory status, 02 sats, niv mask ventilation at night as\n per orders.\n" }, { "category": "Physician ", "chartdate": "2147-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 426836, "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 Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:30 AM\n Metronidazole - 07:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:13 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 07:35 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: 36.6\nC (97.8\n HR: 92 (84 - 122) bpm\n BP: 88/45(55) {80/34(43) - 117/79(112)} mmHg\n RR: 11 (10 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.4 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 1,030 mL\n 100 mL\n PO:\n 1,030 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 745 mL\n 215 mL\n Urine:\n 745 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 285 mL\n -115 mL\n Respiratory support\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, icteric\n Head, Ears, Nose, Throat: Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 8.8 g/dL\n 91 K/uL\n 108 mg/dL\n 0.9 mg/dL\n 18 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 109 mEq/L\n 135 mEq/L\n 26.9 %\n 10.2 K/uL\n [image002.jpg]\n 09:07 AM\n 05:50 AM\n 07:19 AM\n 09:21 AM\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n Plt\n 92\n 86\n 86\n 77\n 91\n Cr\n 0.9\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n TCO2\n 20\n 18\n 17\n Glucose\n 107\n 113\n 129\n 103\n 110\n 99\n 108\n Other labs: PT / PTT / INR:23.5/48.2/2.3, ALT / AST:57/91, Alk Phos / T\n Bili:150/5.6, Amylase / Lipase:126/104, Differential-Neuts:86.4 %,\n Lymph:6.3 %, Mono:6.8 %, Eos:0.5 %, Lactic Acid:3.3 mmol/L, Albumin:2.9\n g/dL, LDH:313 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 41 yo male with hx of HepC and EtOh cirrhosis with 4 admissions to ICU\n this month for altered mental status possibly complicated by sleep\n disordered breathing which have led to intubation each time, currently\n he is back to baseline and has tolerated his CPAP well over the weekend\n with no episodes of morning altered MS\n >Altered Mental status/Intubation: once again he has improved to what\n appears to be near his baseline with lactulose therapy. There is no\n concern for AIP or subclinical status at this point. We deferred trach\n to give a trial of CPAP which he has done well..\n - supportive CPAP at night.\n >Liver failure: followed by liver service, on lactulose, rifax and\n flagy for clearance\n - cont above regimen, added back the diuretic regimen\n - consider Vit K trial if INR remains elevated.\n >Hyponatremia: slowly improving over the past 24 hrs, we will cont to\n trend. His Uosm and Fena were consistent with SIADH\n >Elevated WBC/mild fever: appears to be consistent with stress event as\n the WBC has improved markedly. If course begins to change we will need\n to consider paracentesis although he is on prophylaxis. Notably last\n tap was bland (by cell count) although growing coag neg staph. c.\n dif was neg\n >Low HCO3: likely the lactulose regimen, he has stabilized the\n values for now. Will cont to follow.\n >Portopulmonary hypertension\n continue iloprost via home neb system\n and sildenafil 25TID\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\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: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2147-11-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 427046, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\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: No\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: 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 experienced frequent episodes of desaturations through the\n night., Pt placed on Auto cpap + 6l to maintain spo2. will continue to\n closely monitor.\n" }, { "category": "Physician ", "chartdate": "2147-11-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 427132, "text": "Chief Complaint: delerium/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 41 yo man with cirrhosis and pulmonary HTN, originally admitted to\n hospital on with decreased MS has been called\n out and returned several times. Last night was increasingly agitated\n and confuse. On admission to MICU, agitated, oriented only to self,\n required 4 point restraints. Got Haldol 2.5mg IV twice which did calm\n him down. Started passing stools and MS improved.\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 02:35 AM\n Other medications:\n lactulose\n sildenafil\n protonix\n hep s/q\n synthoid\n cipro\n rifaxamin\n iloprost\n Changes to medical and family history:\n PMHX:\n Grade I varices\n Hep C, ETOH abuse in past, currently on transplant list.\n Hypothyroidism\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 Gastrointestinal: No(t) Abdominal pain\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 70 (70 - 114) bpm\n BP: 98/54(65) {86/40(52) - 116/80(84)} mmHg\n RR: 8 (8 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.2 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 519 mL\n PO:\n 60 mL\n TF:\n IVF:\n Blood products:\n 459 mL\n Total out:\n 0 mL\n 590 mL\n Urine:\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -71 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: No(t) Normocephalic\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, umbilical hernia\n Extremities: no edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, and time, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 7.2 g/dL\n 66 K/uL\n 118 mg/dL\n 1.5 mg/dL\n 17 mEq/L\n 3.3 mEq/L\n 27 mg/dL\n 112 mEq/L\n 142 mEq/L\n 21.0 %\n 5.6 K/uL\n [image002.jpg]\n 09:38 AM\n 02:47 PM\n 06:39 PM\n 04:00 AM\n 03:54 AM\n 06:00 AM\n 08:45 AM\n 12:06 AM\n 05:01 AM\n 07:43 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n 5.6\n Hct\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n 21.4\n 21.0\n Plt\n 92\n 86\n 86\n 77\n 91\n 85\n 74\n 66\n Cr\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n 1.5\n TCO2\n 17\n Glucose\n 129\n 103\n 110\n 99\n 108\n 143\n 118\n 118\n Other labs: PT / PTT / INR:23.5/122.6/2.3, ALT / AST:43/69, Alk Phos /\n T Bili:113/5.9, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:3.9 g/dL, LDH:225 IU/L, Ca++:8.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.3\n mg/dL\n Fluid analysis / Other labs: Ascites fluid with low WBC, cx with\n coag neg staph that has not been treated.\n Assessment and Plan\n HEPATIC : Much improved today, now oriented and calm.\n Continue lactulose. Could have been precipitated by bleed or\n hypovolemia.\n Anemia: Hct has dropped, but not having melena. Transfused 1U.\n Monitor for GIB.\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC: F/U on US results.\n PULMONARY HYPERTENSION (PULM HTN, PHTN): On sildenafil and iloprost\n Acute Renal Failure: Increased creatinine over past two days. be\n somewhat dry. Recently started aldactone and lasix. Hold diuretics.\n Coagulopathy: Unclear why PTT increased, ?effect of s/q heparin. Will\n stop.\n OSA: On CPAP\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2147-11-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 426196, "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: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\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: White / Frothy\n Sputum source/amount: Expectorated / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt extubated and placed on cool aerosol face mask, tolerated\n well at Sats 98, stable BP\n Assessment of breathing comfort: No claim of dyspnea)\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" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426424, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Denies abdominal pain\n Action:\n Monitored\n Response:\n Plan:\n Monitor abd pain\n Knowledge Deficit\n Assessment:\n Oriented x 3, pleasant. asks questions. Often states you should ask my\n mother she would know. anxious at times\n Action:\n Questions reinforced, reassuarance offered.\n Response:\n Calms with reassurance\n Plan:\n Offer reassurance , encourage verbalization.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Na 130 felt stable by team. Excellent appetite\n Action:\n Regular diet to be change to low na. continue 1 l fluid restriction.\n Lasix restarted\n Response:\n Following fluid restriction\n Plan:\n Monitor na and intake. Monitor diuresis\n Hepatic encephalopathy\n Assessment:\n Alert,\n Action:\n Monitor , lactulose,\n Response:\n 1 medium loose stool\n Plan:\n Monitor mental status, bowel movements, continue Lactulose, monitor\n mental status\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Restart meds\n Response:\n Plan:\n .H/O alkalosis, respiratory\n Assessment:\n O2 sats > 93% on ra mostly >95%, breath sounds clear throughout\n Action:\n Monitor respiratory status,o2 sats\n Response:\n O2 sat 93%\n Plan:\n Monitor respiratory status, 02 sats, niv mask ventilation at night as\n per orders.\n" }, { "category": "Nursing", "chartdate": "2147-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426654, "text": "possible OSA\n continue nighttime CPAP (tolerating well thus far).\n - discussion continues re: possible trach. Would clearly be beneficial\n if this process is due to obstructive apnea (though unclear if this is\n the cause). Would also be beneficial if central apnea in that could\n easily be hooked up to vent (but weighing risks, ?need to go to vent\n facility following discharge, increased risk of infections/VAPs) as\n opposed to repeated intubations and potential hypoxic exposures. Will\n continue to follow discussions.\n Hepatic encephalopathy ESLD: Hep C and alcohol cirrhosis\n Assessment:\n Alert oriented x3. ^ mobility steady gait bed to chair. Abd lg firm\n distended ascites increased , + BS, Passing loose stool golden stool\n s/p lactalose.\n Action:\n Received lactulose, rifaximin and flagyl per routine.\n Response:\n Improved encephalopathy, passing > 4loose stool\n Plan:\n Cont lactulose goal >4BM/day, rifaximin, and po flagyl\n Cont lactalose and spironolactone\n continue prophylactic cipro (SBP).\n follow up hepatology recommendations.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Alert oriented x3, Na 135, Foley icteric u/o 25-50cc/hr\n Action:\n Low Na+ diet, continue 1 l fluid restriction, received lasix and\n aldactone\n Response:\n Following fluid restriction, Marginal icteric u/o despite diuretics\n Plan:\n Monitor Na+ , maintain Fluid restriction to 1 liter/24hrs.\n" }, { "category": "Physician ", "chartdate": "2147-11-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 427039, "text": "Chief Complaint: altered mental status\n HPI:\n Please see admission H&P as well as prior transfer notes for full\n details, in brief Mr. is a 41 yo M with PMH of pulmonary\n hypertension, ESLD from alcohol and hepatitis C on transplant list,\n admitted with altered mental status hepatic encephalopathy in\n the setting of decreased BMs. He was initially transferred from OSH\n intubated concern for aspiration event however he was extubated\n shortly after arrival. Following extubation, his hospital course has\n been complicated but several intubations for unresponsiveness of\n unclear etiology. ABG's done at that time repeatedly show a\n respiratory alkalosis, most recent from Code Blue called with ABG\n 7.49/22/169/17. Following that admission he was admitted to the MICU\n Green service. His lactulose was increased to include a 2am dose given\n that most of his unresponsive episodes occur at night. In addition, he\n was started on CPAP overnight and with these two interventions did well\n in the MICU and was called out to the floor .\n .\n In addition, he had one episode concerning for SBO during one of his\n ICU stay's with abdominal pain, lack of BM despite very high amounts of\n lactulose and KUB c/w bowel obstruction vs ileus. Bowel movements\n resumed following administration of oral contrast for CT scan.\n .\n On the evening of transfer he triggered on the floor for altered mental\n status and lack of bowel movement this evening despite multiple doses\n of lactulose. On review of records, he did have 6 bowel movements\n earlier in the day, however seemed to have stopped responding to\n lactulose during the evening. Of note, his creatinine was elevated to\n 1.6 above baseline of 1 which is new for him.\n Patient admitted from: \n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 01:45 AM\n Other medications:\n Medications on transfer:\n Lactulose Enema 1000 mL PR ONCE\n Levothyroxine Sodium 88 mcg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN\n Pantoprazole 40 mg PO Q24H\n Ciprofloxacin HCl 250 mg PO Q24H\n Prochlorperazine 10 mg IV Q6H:PRN nausea\n Heparin 5000 UNIT SC TID\n Rifaximin 400 mg PO TID\n Iloprost *NF* 10 mcg/mL Inhalation 2.5 mL 6xday\n Lactulose 60 mL PO Q2H:PRN titrate to bowel movements per day.\n Lactulose 45 mL PO QID titrate to bowel movements per day\n Lactulose 45 mL PO Q2AM\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n NC\n Occupation:\n Drugs: denies\n Tobacco: quit this year\n Alcohol: quit 11 years ago\n Other:\n Review of systems:\n Flowsheet Data as of 03:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.6\nC (96\n HR: 97 (85 - 114) bpm\n BP: 106/71(78) {98/47(59) - 116/80(84)} mmHg\n RR: 9 (8 - 16) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.2 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 47 mL\n PO:\n TF:\n IVF:\n Blood products:\n 47 mL\n Total out:\n 0 mL\n 390 mL\n Urine:\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -338 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///16/\n Physical Examination\n vitals: T96.8 HR 99 BP 111/80 RR 14 98%RA\n gen: Awake and alert, oriented to person, repeatedly answers\n \"wednesday\" to other orientation questions\n heent: icteric sclera, EOMI, PERRL\n neck: supple, no LAD\n pulm: CTAB anteriorly\n cv:RRR s1 s2 no mrg\n abd: distended, non tender, umbilical hernia distended no compressible,\n BS+\n extr: no pedal edema, dp's palpable bilaterally\n Labs / Radiology\n 74 K/uL\n 8.3 g/dL\n 118 mg/dL\n 1.6 mg/dL\n 28 mg/dL\n 16 mEq/L\n 110 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 24.3 %\n 6.8 K/uL\n [image002.jpg]\n \n 2:33 A11/20/ 07:19 AM\n \n 10:20 P11/20/ 09:21 AM\n \n 1:20 P11/20/ 09:38 AM\n \n 11:50 P11/20/ 02:47 PM\n \n 1:20 A11/20/ 06:39 PM\n \n 7:20 P11/21/ 04:00 AM\n 1//11/006\n 1:23 P11/22/ 03:54 AM\n \n 1:20 P11/23/ 06:00 AM\n \n 11:20 P11/24/ 08:45 AM\n \n 4:20 P11/26/ 12:06 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n Plt\n 92\n 86\n 86\n 77\n 91\n 85\n 74\n Cr\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n TC02\n 18\n 17\n Glucose\n 113\n 129\n 103\n 110\n 99\n 108\n 143\n 118\n Other labs: PT / PTT / INR:25.1/150.0/2.5, ALT / AST:51/80, Alk Phos /\n T Bili:135/5.7, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:2.8 g/dL, LDH:269 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.1\n mg/dL\n Fluid analysis / Other labs: labs:\n Na 134 K 3.4 Cl 107 HCO 16 BUN 28 Creat 1.6 Gluc 97\n Ca 8.7 Mg 1.9 P 3.4\n AST 87 ALT 55 AP 149 LDH 287 Tbili 5.3 Alb 2.5\n WBC 8.7 HCT 23.1 PLT 84\n PTT 63.4 INR 2.3\n Microbiology: Micro:\n Cdiff negative\n Peritoneal Fluid: +coag neg staph\n Assessment and Plan\n Mr. is a 41 yo male with ESLD, pulm HTN, originally admitted\n with AMS now with multiple MICU transfers and intubations for\n unresponsiveness, now re-transferred to MICU for altered mental\n status.\n .\n #Altered Mental Status: most likely hepatic encephalopathy and poor\n response to po lactulse. Does have recent episode of partial sbo/ileus\n which resolved on its own, which may be contributing in this case. He\n did have worsened renal function this morning somewhat concerning for\n possible development of HRS although may have been due to dehydration.\n Worsened renal function could also be responsible for worsened mental\n status. Other possiblility is GI bleed given HCT drop to 23, which\n could also precipitate encephalopathy. Infection also possible, with\n most likely source being SBP however he has had several para's neg for\n SBP based on cell count/diff however, culture from positive for\n coag neg staph. Portal vein thrombosis is also a consideration.\n -PR lactulose if able although have been unable agitation\n -continue with po lactulose 45ml QID and 2 am dose to prevent early\n morning unresponsiveness (have not been able to give since arrival in\n ICU agitation and combativeness)\n -CPAP overnight which has helped prevent early am unresponsiveness\n during recent ICU stay\n -consider repeat para in am if no improvement\n -Abd u/s in the AM to eval for portal vein thrombosis\n -consider empiric abx for SBP if unable to tap in the AM, would cover\n for coag neg staph given ascites fluid culture w/coag neg staph from\n , although thought likely to be a contaminant.\n -haldol 2.5-5mg IV for agitation/combativeness\n .\n #Coagulopathy - likely ESLD and poor nutrition, PTT >150 which may\n be due to heparin sq injections given very minimal SQ tissue\n -repeat coags in am\n -ffp if needed for bleeding\n .\n #Acute Renal Failure: creatinine elevated this am up to 1.6 this\n morning, thought by the team dehydration as diuretics recently\n started. Diuretics held this am and he was given albumin.\n -f/u creatine\n -albumin/IVF prn\n -send UA and culture\n .\n # ESLD: ETOH/HepC, +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list.\n - continue lactulose/rifaximin as above.\n - guaic stools\n - lasix and spironolactone d/c'd arf\n - continue cipro for sbp prophylaxis\n -bilit/coags/hct/plt generally stable\n -monitor tbili, lft's\n .\n # pulmonary HTN: pt breathing comfortably on RA presently.\n - continue iloprost\n - continue sildenafil.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Currently HCT\n somewhat lower than usual at 23,slightly concerning for possibility of\n GI ooze. PLT's have been stable.\n - guaic stools.\n - trend HCT.\n .\n # hypothyroidism: dose recently increased persistently elevated\n TSH.\n - continue levothyroxine at 88mcg/qdaily.\n ICU Care\n Nutrition:NPO except meds while encephalopathic\n Glycemic Control:\n Lines: PIV\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication Mother \n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2147-11-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 427040, "text": "Chief Complaint: altered mental status\n HPI:\n Please see admission H&P as well as prior transfer notes for full\n details, in brief Mr. is a 41 yo M with PMH of pulmonary\n hypertension, ESLD from alcohol and hepatitis C on transplant list,\n admitted with altered mental status hepatic encephalopathy in\n the setting of decreased BMs. He was initially transferred from OSH\n intubated concern for aspiration event however he was extubated\n shortly after arrival. Following extubation, his hospital course has\n been complicated but several intubations for unresponsiveness of\n unclear etiology. ABG's done at that time repeatedly show a\n respiratory alkalosis, most recent from Code Blue called with ABG\n 7.49/22/169/17. Following that admission he was admitted to the MICU\n Green service. His lactulose was increased to include a 2am dose given\n that most of his unresponsive episodes occur at night. In addition, he\n was started on CPAP overnight and with these two interventions did well\n in the MICU and was called out to the floor .\n .\n In addition, he had one episode concerning for SBO during one of his\n ICU stay's with abdominal pain, lack of BM despite very high amounts of\n lactulose and KUB c/w bowel obstruction vs ileus. Bowel movements\n resumed following administration of oral contrast for CT scan.\n .\n On the evening of transfer he triggered on the floor for altered mental\n status and lack of bowel movement this evening despite multiple doses\n of lactulose. On review of records, he did have 6 bowel movements\n earlier in the day, however seemed to have stopped responding to\n lactulose during the evening. Of note, his creatinine was elevated to\n 1.6 above baseline of 1 which is new for him.\n Patient admitted from: \n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 01:45 AM\n Other medications:\n Medications on transfer:\n Lactulose Enema 1000 mL PR ONCE\n Levothyroxine Sodium 88 mcg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN\n Pantoprazole 40 mg PO Q24H\n Ciprofloxacin HCl 250 mg PO Q24H\n Prochlorperazine 10 mg IV Q6H:PRN nausea\n Heparin 5000 UNIT SC TID\n Rifaximin 400 mg PO TID\n Iloprost *NF* 10 mcg/mL Inhalation 2.5 mL 6xday\n Lactulose 60 mL PO Q2H:PRN titrate to bowel movements per day.\n Lactulose 45 mL PO QID titrate to bowel movements per day\n Lactulose 45 mL PO Q2AM\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n NC\n Occupation:\n Drugs: denies\n Tobacco: quit this year\n Alcohol: quit 11 years ago\n Other:\n Review of systems:\n Flowsheet Data as of 03:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.6\nC (96\n HR: 97 (85 - 114) bpm\n BP: 106/71(78) {98/47(59) - 116/80(84)} mmHg\n RR: 9 (8 - 16) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 63.2 kg (admission): 65 kg\n Height: 66 Inch\n Total In:\n 47 mL\n PO:\n TF:\n IVF:\n Blood products:\n 47 mL\n Total out:\n 0 mL\n 390 mL\n Urine:\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -338 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///16/\n Physical Examination\n vitals: T96.8 HR 99 BP 111/80 RR 14 98%RA\n gen: Awake and alert, oriented to person, repeatedly answers\n \"wednesday\" to other orientation questions\n heent: icteric sclera, EOMI, PERRL\n neck: supple, no LAD\n pulm: CTAB anteriorly\n cv:RRR s1 s2 no mrg\n abd: distended, non tender, umbilical hernia distended no compressible,\n BS+\n extr: no pedal edema, dp's palpable bilaterally\n Labs / Radiology\n 74 K/uL\n 8.3 g/dL\n 118 mg/dL\n 1.6 mg/dL\n 28 mg/dL\n 16 mEq/L\n 110 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 24.3 %\n 6.8 K/uL\n [image002.jpg]\n \n 2:33 A11/20/ 07:19 AM\n \n 10:20 P11/20/ 09:21 AM\n \n 1:20 P11/20/ 09:38 AM\n \n 11:50 P11/20/ 02:47 PM\n \n 1:20 A11/20/ 06:39 PM\n \n 7:20 P11/21/ 04:00 AM\n 1//11/006\n 1:23 P11/22/ 03:54 AM\n \n 1:20 P11/23/ 06:00 AM\n \n 11:20 P11/24/ 08:45 AM\n \n 4:20 P11/26/ 12:06 AM\n WBC\n 9.8\n 18.6\n 14.7\n 10.0\n 10.2\n 7.5\n 6.8\n Hct\n 30\n 28.1\n 27.3\n 25.9\n 25.1\n 26.9\n 26.1\n 24.3\n Plt\n 92\n 86\n 86\n 77\n 91\n 85\n 74\n Cr\n 1.0\n 1.0\n 1.1\n 0.8\n 0.9\n 1.2\n 1.6\n TC02\n 18\n 17\n Glucose\n 113\n 129\n 103\n 110\n 99\n 108\n 143\n 118\n Other labs: PT / PTT / INR:25.1/150.0/2.5, ALT / AST:51/80, Alk Phos /\n T Bili:135/5.7, Amylase / Lipase:126/104, Differential-Neuts:79.9 %,\n Lymph:13.0 %, Mono:6.5 %, Eos:0.4 %, Lactic Acid:3.3 mmol/L,\n Albumin:2.8 g/dL, LDH:269 IU/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.1\n mg/dL\n Fluid analysis / Other labs: labs:\n Na 134 K 3.4 Cl 107 HCO 16 BUN 28 Creat 1.6 Gluc 97\n Ca 8.7 Mg 1.9 P 3.4\n AST 87 ALT 55 AP 149 LDH 287 Tbili 5.3 Alb 2.5\n WBC 8.7 HCT 23.1 PLT 84\n PTT 63.4 INR 2.3\n Microbiology: Micro:\n Cdiff negative\n Peritoneal Fluid: +coag neg staph\n Assessment and Plan\n Mr. is a 41 yo male with ESLD, pulm HTN, originally admitted\n with AMS now with multiple MICU transfers and intubations for\n unresponsiveness, now re-transferred to MICU for altered mental\n status.\n .\n #Altered Mental Status: most likely hepatic encephalopathy and poor\n response to po lactulse. Does have recent episode of partial sbo/ileus\n which resolved on its own, which may be contributing in this case. He\n did have worsened renal function this morning somewhat concerning for\n possible development of HRS although may have been due to dehydration.\n Worsened renal function could also be responsible for worsened mental\n status. Other possiblility is GI bleed given HCT drop to 23, which\n could also precipitate encephalopathy. Infection also possible, with\n most likely source being SBP however he has had several para's neg for\n SBP based on cell count/diff however, culture from positive for\n coag neg staph. Portal vein thrombosis is also a consideration.\n -PR lactulose if able although have been unable agitation\n -continue with po lactulose 45ml QID and 2 am dose to prevent early\n morning unresponsiveness (have not been able to give since arrival in\n ICU agitation and combativeness)\n -CPAP overnight which has helped prevent early am unresponsiveness\n during recent ICU stay\n -consider repeat para in am if no improvement\n -Abd u/s in the AM to eval for portal vein thrombosis\n -consider empiric abx for SBP if unable to tap in the AM, would cover\n for coag neg staph given ascites fluid culture w/coag neg staph from\n , although thought likely to be a contaminant.\n -haldol 2.5-5mg IV for agitation/combativeness\n .\n #Agitation/combativeness\n likely exacerbation of hepatic\n encephalopathy\n -haldol prn\n -restraints as needed for aggression toward staff\n -work up of encephalopathy as above\n .\n #Coagulopathy - likely ESLD and poor nutrition, PTT >150 which may\n be due to heparin sq injections given very minimal SQ tissue\n -repeat coags in am\n -ffp if needed for bleeding/NGT placement\n .\n #Acute Renal Failure: creatinine elevated this am up to 1.6 this\n morning, thought by the team dehydration as diuretics recently\n started. Diuretics held this am and he was given albumin.\n -f/u creatine\n -albumin/IVF prn\n -send UA and culture\n .\n # ESLD: ETOH/HepC, +h/o hepatic encephalopathy, known varices,\n followed by Dr. , on transplant list.\n - continue lactulose/rifaximin as above.\n - guaic stools\n - lasix and spironolactone d/c'd arf\n - continue cipro for sbp prophylaxis\n -bilit/coags/hct/plt generally stable\n -monitor tbili, lft's\n .\n # pulmonary HTN: pt breathing comfortably on RA presently.\n - continue iloprost\n - continue sildenafil.\n .\n # anemia/thrombocytopenia: baseline hct ~27, plt 70-90. Currently HCT\n somewhat lower than usual at 23,slightly concerning for possibility of\n GI ooze. PLT's have been stable.\n - guaic stools.\n - trend HCT.\n .\n # hypothyroidism: dose recently increased persistently elevated\n TSH.\n - continue levothyroxine at 88mcg/qdaily.\n ICU Care\n Nutrition:NPO except meds while encephalopathic\n Glycemic Control:\n Lines: PIV\n 18 Gauge - 12:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication Mother \n status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426324, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n" }, { "category": "Nursing", "chartdate": "2147-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 426325, "text": "Pt is a 41 yo man with PMH pulmonary HTN, ESLD sec to ETOH/hep C\n transplant list, grade 1 varices, hypothyroid, anxiety disorder, hx\n ETOH quit 11 yrs ago and IVDU in past, osteoporosis; Pt originally\n admitted on from OSH after found unresponsive by mother in AM,\n intubated x 1 day\n extubated\n to floor, next AM pt was reintubated\n for unresponsiveness, neuro w/u\ns including CT/MRI have been\n essentially neg x for evidence hepatic encephalopathy\n treated\n w/lactulose; back to floor on \n receiving diuretics then held for\n hyponatremia. On AM, pt again found unresponsive/unarrousable on\n 10, no gag reflex, VSS but intubated for airway protection at ~\n 0730; to CCU\n awoke, following commands\n extubated at 1645 on .\n Unresponsive on at 0730 hrs , intubated for airway protection &\n tranx to MICU 07 from 10 for further management\n Assessment:\n Received On vent PS/50%/. satting at high >95\ns. ABG with resp\n alkalosis. Extubated at 1100 hrs. Was on face tent. Room air since\n 1500 hrs.\n Action:\n Electively extubated at 1100 hrs successfully. Placed on face tent.\n After that. On room air since 1500 hrs.\n Response:\n Satting at high 90\ns on room air. Denied SOB. Sitting up at chair.\n Plan:\n Continue monitoring his resp status. Will place on CPAP at night .\n H/O cirrhosis of liver, alcoholic\n Assessment:\n Abdomen firm distended, ascittis. hepatic encephalopathy, LFT\n elevated. & coagulopathic. H/O epistaxis.\n Action:\n lactulose 60 mlTID ( scheduled) Lactulose 60 ml Q2 hr PRN X1 given.\n Up to BSC X1.\n Response:\n Small Loose stool X1. Sitting Up at chair.\n Plan:\n Cont lactulose as ordered, cont frequent turning and skin care w/\n barrier cream.\n Respiratory Alkalosis.\n Assessment:\n On vent PS/50%/. satting at high >95\ns. ABG with resp alkalosis.\n Action:\n Suctioned frequently for thick yellowish secretions in copious to\n moderate amt\ns. MD notified.. Around 0330 hrs, patient is awake and\n appropriate.\n Response:\n Pt. placed on Propofol gtt for sedation.\n Plan:\n Continue monitoring his resp status & Discuss possible trach procedure\n later this am.\n Impaired skin integrity\n Assessment:\n Pt with multiple dried skin tears over Left lower abdomen. Site of\n previous paracentesis with skin tears d/t tape of dressings. Versivia\n dressing placed over site. Left arm bruised.Rt upper back bruised.\n Left hip is reddened. Bruises at rt upper chhek from Adhesive tape.\n Action:\n Protective skin barrier cream applied. Repositioned frequently.\n Response:\n No change at this time.\n Plan:\n Will cont turning q 2 hrly. Monitor his skin for integrity. Sitting\n up at chair.\n" }, { "category": "Physician ", "chartdate": "2147-11-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 425905, "text": "Chief Complaint: altered mental status, intubated for airway\n protection\n HPI:\n Mr. is a 41 year old male admitted 15 days ago for hepatic\n encephalopathy. He has been intubated 4x for altered mental status\n during this hospital stay. He now returns to MICU green after being\n found somnolent with blood in nose. An NG tube was placed for unclear\n reasons (?concern for GI bleeding) and code blue called. Patient\n intubated for airway protection. Maintained O2 sats >90 and never lost\n pulse, SBPs in 100s-110s. ABG prior to intubation (?prior to bagging)\n 7.50/22/87. Cannot currently locate MARs but not written for any\n narcs/benzos/sedatives. Unclear if wearing CPAP overnight (not wearing\n at time of event).\n Initially admitted to MICU from OSH from . Called out to\n floor on the evening of and returned to the MICU early AM on \n for a similar episode. Again had a MICU stay from to and\n has been on the liver floor since . All episodes prompt code blue\n calls and intubation for airway protection and occur between 6 and 8\n am. No clearly documented hypercarbic failure. On had sleep\n study to evaluate for sleep disordered breathing as these events keep\n occurring in early AM. RDI 26.8 (moderate) but 5.6 by Medicare\n criteria (mild). Few desats to mid-low 80s and one desat to 76. Not\n clear that he reached REM sleep. Recommended to try CPAP at low\n pressures, initiated 2 nights ago but not clear that he had this last\n evening prior to event. Sildenifil stopped for concern of exacerbating\n OSA. For hepatic encephalopathy, continues on TID and prn lactulose,\n rifaximin, and flagyl also started at 250 TID.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: upon transfer\n - Rifaximin 400 mg PO TID\n - Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n - Heparin 5000 UNIT SC TID\n - Iloprost *NF* 2.5 mcg Inhalation q2h while awake * Patient Taking Own\n Meds *\n - Lactulose 60 mL PO TID and Q2H:PRN\n titrate to bowel movements per day.\n - Ciprofloxacin HCl 250 mg PO Q24H\n - Levothyroxine Sodium 88 mcg PO DAILY\n - MetRONIDAZOLE (FLagyl) 250 mg PO Q8H\n - Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n -ESLD secondary to alcohol and hepatitis C on transplant list\n -grade 1 esophageal varices\n -pulmonary hypertension (see prior admit notes for details)\n -hypothyroidism\n -anxiety disorder\n -h/o ETOH and IVDU\n -osteoporosis\n Mother has diabetes and hypertension. Father has rheumatic heart\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his mother. Quit alcohol use 11 years ago reportedly.\n Remote history of IVDU but nothing currently. Quit smoking this year.\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n BP: 121/60(75) {0/0(0) - 0/0(0)} mmHg\n Wgt (current): 69.9 kg (admission): 78.6 kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Ve: 7.6 L/min\n Physical Examination\n General: intubated.\n HEENT: NC/AT. Sclera icteric. Pupils dilated but symmetric and\n reactive. Eyes deviated slightly to right and not spontaneously\n moving. Dried blood in bilateral nares. MMM, ETT and OGT in place.\n Neck: No adenopathy, no clear JVD elevation.\n Chest: Very coarse/rhoncherous on vent. No wheezes/crackles.\n Heart: Regular though distant behind course breath sounds.\n Abdomen: +BS, soft, distended but nontender. Mostly tympanitic with\n peripheral dullness. L para site dressed. Linear healing scab on\n abdomen.\n Extrem: Warm, minimal edema.\n Neuro. Eyes dilated and looking slightly toward right. No blink to\n confrontation. Not following commands. Slight grimace to sternal\n rub. No withdrawal to pain of extremities. Spontaneously dorsiflexes\n bilat feet when stimulated, no other movement to pain. Cannot obtain\n babinski or clonus due to dorsiflexion. R leg with ?increased\n tone/difficulty relaxing.\n Labs / Radiology\n 123 K/uL\n 9.4 g/dL\n 113 mg/dL\n 0.8 mg/dL\n 22 mg/dL\n 20 mEq/L\n 98 mEq/L\n 4.1 mEq/L\n 124 mEq/L\n 30\n 10.6 K/uL\n [image002.jpg]\n \n 2:33 A11/15/ 09:34 AM\n \n 10:20 P11/15/ 12:56 PM\n \n 1:20 P11/15/ 09:18 PM\n \n 11:50 P11/16/ 03:19 AM\n \n 1:20 A11/16/ 07:44 PM\n \n 7:20 P11/17/ 04:42 AM\n 1//11/006\n 1:23 P11/17/ 09:07 AM\n \n 1:20 P11/20/ 07:19 AM\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.9\n 10.6\n Hct\n 28.8\n 27.9\n 30\n Plt\n 131\n 123\n Cr\n 1.1\n 1.0\n 1.1\n 0.8\n 0.8\n TC02\n 20\n 20\n Glucose\n 98\n 107\n 114\n 143\n 105\n 113\n Other labs: PT / PTT / INR:22.2/77.7/2.1, ALT / AST:86/150, Alk Phos /\n T Bili:142/7.2, Albumin:2.8 g/dL, LDH:310 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n ABG 7.50/22/87\n Peritoneal fluid ()\n 70 WBCs (7% polys), no growth.\n CXR: ETT ~1.8 cm above carina, OGT in place. Improved lung volumes.\n No focal infiltrate or pulmonary edema.\n Assessment and Plan\n A/P: 41 yo M with pulmonary hypertension, ESLD on transplant list with\n Hep C cirrhosis, alcoholic cirrhosis, hypothyroidism who presents with\n his fourth episode of altered mental status requiring intubation for\n airway protection.\n # Somnolence. Again prompting respiratory code and intubation for\n airway protection on floor. Differential has included hepatic\n encephalopathy (worsening overnight with no overnight doses of\n lactulose), OSA or other sleep disordered breathing, or new type of\n neurologic event. Also consider electrolyte abnormality (alkalemia\n stable, hyponatremia with improvement overnight), infection (SBP - last\n tap 3 days ago, afebrile, no abdominal tenderness; CXR clear, consider\n urine/blood). Glucose normal. Regarding hepatic encephalopathy,\n patient getting lactulose, rifaximin, and low dose flagyl. Regarding\n sleep disorder breathing, patient had sleep study 3 nights ago with\n suggestion of mild-mod OSA, no REM sleep achieved. On CPAP 2 nights\n ago for trial, unclear if was getting this last night. Currently\n worrisome is that he is minimally responsive currently - ?neurologic\n event or subclincal status, vs. residual medication effect or hepatic\n encephalopathy. Neurologic exam similar to previous presentations\n (initially with minimal responsiveness, then rapidly improving). Most\n likely explanation is severe hepatic encephalopathy with overnight\n break from lactulose, as these episodes have all occurred within a few\n hours of 8am meds (no lactulose for at least 8-10 hours). If sleep\n disordered breathing related, could expect these events to occur\n sporadically throughout night instead of consistently 6-7am.\n - Treat aggressively for hepatic encephalopathy - lactulose\n Q2H to start until mental status clearing, continue rifaximin and\n flagyl. need specific overnight wakeup for lactulose.\n - Possible OSA\n consider CPAP upon extubation (trial 2 nights\n ago).\n - Management of hyponatremia as below.\n - Infectious workup\n check UA; no indication to tap ascites\n currently (last tap 3 days ago), consider blood cultures. No fever,\n leukocytosis, or systemic signs of infection.\n - Consider tox screens, have been negative except benzos\n (after received in hospital) in past.\n - Extubation once mental status clears (keep on for now).\n # Respiratory alkalosis/metabolic acidosis. Stable pH at 7.50 with\n significant respiratory alkalemia. Taking large breaths on vent.\n Likely related to ascites/large abdomen with other hormonal effects\n from cirrhosis. Also with metabolic acidosis\n in part compensatory\n for respiratory alkalosis, but bicarb dropping throughout this\n admission, likely an effect of increasing lactulose requirements\n leading to worsening diarrhea and bicarb losses.\n - Continue with PSV on vent at current settings ().\n - Check urinary anion gap\n anticipate seeing negative gap due\n to GI losses of bicarb.\n # Hyponatremia: Stable in 120s. Has been in the low 130s previously on\n this admission. Yesterday with Na 118, up to 126 this AM. Unlikely to\n be primary cause of altered mental status.\n - 1 L fluid restriction once taking PO.\n - Hold diuretics\n - Avoid rapid correction of Na if drops again.\n # ESLD: Hep C and alcohol cirrhosis.\n - lactulose, rifaximin, flagyl as above.\n -holding diuretics for now\n -continue prophylactic cipro (SBP).\n - follow up hepatology recs\n # Pulmonary HTN: on iloprost and sildenifil at home. Sildenifil\n discontinued yesterday due to concern of worsening OSA. No evidence\n that this or other decompensations were related to pulmonary\n hypertension, as remains hemodynamically stable during these events.\n - continue to hold both sildenifil and iloprost for now\n (iloprost can resume once extubated).\n # Epistaxis. Noted to have blood in nose during event. No current\n bleeding. Neither OGT or ETT suctioning returning blood.\n - continue to monitor for now\n - FFP and platelets is needed if has recurrent bleeding.\n # Hypothyroidism: continue levothyroxine\n ICU Care\n Nutrition: NPO for now, TFs if prolonged intubation. Fluid restrict\n once taking PO\n Glycemic Control: Regular insulin sliding scale if needed.\n Lines: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\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": "Echo", "chartdate": "2147-11-21 00:00:00.000", "description": "Report", "row_id": 84917, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary hypertension.\nHeight: (in) 66\nWeight (lb): 165\nBSA (m2): 1.84 m2\nBP (mm Hg): 124/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 14:11\nTest: TTE (Congenital, 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 size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Secundum ASD. Increased IVC\ndiameter (>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). False LV tendon (normal variant). TDI E/e' < 8,\nsuggesting normal PCWP (<12mmHg). 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: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Ascites.\n\nConclusions:\nThe left atrium is normal in size. A secundum type atrial septal defect is\nprobably present. The estimated right atrial pressure is 10-20mmHg. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are structurally normal. There is no mitral valve prolapse.\nMild to moderate (+) mitral regurgitation is seen. There is mild to\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild to moderate pulmonary hypertension (estimated PASP 42-52 mm\nHg). Preserved regional and global biventricular systolic function. Mild to\nmoderate mitral regurgitation. Probable secundum type atrial septal defect\n(known positive bubble study on ).\n\nCompared with the prior study (images reviewed) of , estimated\npulmonary artery systolic pressure is slightly higher (IVC not well visualized\non prior study).\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-28 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1044646, "text": " 1:20 AM\n MR HEAD W/O CONTRAST; MRA NECK W/CONTRAST Clip # \n Reason: r/o stroke\n Admitting Diagnosis: ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, hepatic encephalopathy, altered mental status,\n with RLE weakness.\n REASON FOR THIS EXAMINATION:\n r/o stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:16 PM\n No acute infarct. Normal MRA of the neck.\n ______________________________________________________________________________\n FINAL REPORT\n MRI BRAIN AND MRA OF THE NECK\n\n CLINICAL INFORMATION: Patient with cirrhosis, hepatic encephalopathy, and\n altered mental status with right lower extremity weakness; rule out stroke.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility, and diffusion axial\n images of the brain were acquired. Gadolinium-enhanced MRA of the neck\n obtained.\n\n FINDINGS:\n\n BRAIN MRI:\n\n No evidence of acute infarct on diffusion images. Mild periventricular and\n subcortical changes of small vessel disease are seen without midline shift,\n mass effect, or hydrocephalus. Increased signal is seen in the basal ganglia\n on pre-gadolinium T1 sagittal images which could be consistent with patient's\n clinical diagnosis of hepatic encephalopathy.\n\n A small area of hyperintensity is seen adjacent to the right side of the\n sphenoid sinus on T1 and T2 images which area on the previous CT demonstrates\n low density within the bone. This could be secondary to a focal fatty\n deposit. This most likely is an incidental finding.\n\n IMPRESSION: No acute infarct seen. Mild changes of small vessel disease.\n\n MRA OF THE NECK:\n\n The gadolinium-enhanced neck MRA demonstrates normal flow in the carotid and\n vertebral arteries without stenosis and occlusion.\n\n The intracranial circulation is visualized, except for partial visualization\n of left middle cerebral artery bifurcation. No abnormalities are seen in the\n major arterial structures of the anterior and posterior circulation on the\n neck MRA.\n\n (Over)\n\n 1:20 AM\n MR HEAD W/O CONTRAST; MRA NECK W/CONTRAST Clip # \n Reason: r/o stroke\n Admitting Diagnosis: ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Normal MRA of the neck.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-28 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1044647, "text": ", MED MICU-7 1:20 AM\n MR HEAD W/O CONTRAST; MRA NECK W/CONTRAST Clip # \n Reason: r/o stroke\n Admitting Diagnosis: ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, hepatic encephalopathy, altered mental status,\n with RLE weakness.\n REASON FOR THIS EXAMINATION:\n r/o stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute infarct. Normal MRA of the neck.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1048003, "text": " 12:06 AM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate for SBO\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with decreasing mental status, no bowel movement despite\n multiple (6) doses of lactulose\n REASON FOR THIS EXAMINATION:\n please evaluate for SBO\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with altered mental status, no recent bowel\n movements despite multiple doses of lactulose. Evaluate for small-bowel\n obstruction.\n\n FINDINGS: Single view of the abdomen in comparison to . The\n multiple dilated bowel loops and air-fluid levels are no longer appreciated.\n Significant ascites limits further interpretation. There are no grossly\n dilated bowel loops, or supine evidence of free air.\n\n IMPRESSION: Technically limited study. No grossly dilated bowel loops or\n supine evidence of free air.\n\n" }, { "category": "Radiology", "chartdate": "2147-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1048197, "text": " 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New fever\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with AMS hepatic encephalopathy, now with new fever.\n REASON FOR THIS EXAMINATION:\n New fever\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatic encephalopathy. Now new fever.\n\n CHEST, SINGLE AP VIEW, LORDOTIC POSITIONING:\n\n The heart is not enlarged. There is no CHF, focal infiltrate, or effusion.\n Compared with , the ET tube and NG tube have been removed. Note is\n made of a subtle narrowing of the upper trachea, at a level approximately 6.1\n cm above the carina -- ? subtle tracheomalacia.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044681, "text": " 8:56 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for ngt placement.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, s/p extubation with ngt placement.\n REASON FOR THIS EXAMINATION:\n assess for ngt placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n REASON FOR EXAM: Cirrhosis status post extubation and nasogastric tube\n placement.\n\n Since earlier today, the patient was extubated. A nasogastric tube ends in\n the pyloric region.\n\n Lung volumes are persistently low with bibasilar atelectasis. There is\n overall no other change since earlier today.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046010, "text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for aspiration or pneumonia.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with change of mental status and ? of aspiration.\n REASON FOR THIS EXAMINATION:\n Please evaluate for aspiration or pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mental status change, evaluate for aspiration.\n\n COMPARISON: .\n\n FINDINGS: Supine AP view of the chest was obtained. There is an ET tube 2.5\n cm above the carina as well as an NG tube in which the side holes are at\n the level of the distal esophagus and should be advanced. The lung volumes are\n decreased. The lungs appear clear without evidence of edema or consolidation.\n The cardiopericardial silhouette is unchanged. There are no effusions.\n\n IMPRESSION: Decreased lung volumes. NG tube should be advanced.\n\n" }, { "category": "Radiology", "chartdate": "2147-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044419, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement, infiltrate?\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with altered mental status being intubated\n REASON FOR THIS EXAMINATION:\n tube placement, infiltrate?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 11:45 AM\n Endotracheal tube 1.1 cm from the carina and will need to be withdrawn\n approximately 3 cm. There is bilateral pulmonary vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 41-year-old man with altered mental status and intubation. Evaluate\n for tube placement or infiltrate.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The tip of the endotracheal tube is 1.1 cm from the carina and will\n need to be pulled back approximately 3 cm. There has been interval removal of\n a nasogastric tube. The cardiac silhouette and hilar and mediastinal contours\n are unchanged in appearance allowing for technical differences due to low lung\n volumes. There is slight prominence of bilateral interstitial markings\n suggestive of mild volume overload. There are no pleural effusions. There is\n no pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube 1.1 cm from the carina and will need to be withdrawn\n approximately 3 cm.\n 2. Pulmonary vascular congestion suggestive of volume overload. There are no\n pleural effusions.\n\n The findings of this study were communicated with Dr. at 11:00\n a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044420, "text": ", MED FA10 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement, infiltrate?\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with altered mental status being intubated\n REASON FOR THIS EXAMINATION:\n tube placement, infiltrate?\n ______________________________________________________________________________\n PFI REPORT\n Endotracheal tube 1.1 cm from the carina and will need to be withdrawn\n approximately 3 cm. There is bilateral pulmonary vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1044456, "text": " 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, elevated INR,new altered mental status\n requiring intubation\n REASON FOR THIS EXAMINATION:\n eval for acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 2:05 PM\n No evidence of hemorrhage. Possible partial collapse of the superior endplate\n of the C5 vertebral body. If not previously evaluated, recommend radiographs\n of the cervical spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 41-year-old male with cirrhosis and elevated INR and\n now altered mental status requiring intubation. Please evaluate for acute\n bleed.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n No fractures are identified.\n\n On the scout radiograph, there is apparent collapse of the superior endplate\n of the C5 vertebral body. This area is obscured by overlapping shadows. If\n no prior evaluation of the cervical spine has been done, recommend radiographs\n of the cervical spine.\n\n IMPRESSION:\n\n No hemorrhage identified. Possible partial collapse of the superior endplate\n of the C5 vertebral body; if not previously evaluated, recommend radiographs\n of the cervical spine.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044663, "text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with HCV cirrhosis, AMS secondary to ecephalopathy. intubated.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: HCV cirrhosis, encephalopathy. Intubated, interval change.\n\n Since yesterday, ETT tip is now 4 cm above the carina. A nasogastric tube was\n installed with its tip in the stomach. Lung volumes remain low. There is no\n interstitial edema and no focal area of consolidation. The cardiomediastinal\n silhouette and hilar contours are normal accounting for very low lung volumes.\n\n" }, { "category": "Radiology", "chartdate": "2147-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1044457, "text": ", MED MICU-7 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, elevated INR,new altered mental status\n requiring intubation\n REASON FOR THIS EXAMINATION:\n eval for acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of hemorrhage. Possible partial collapse of the superior endplate\n of the C5 vertebral body. If not previously evaluated, recommend radiographs\n of the cervical spine.\n\n" }, { "category": "Radiology", "chartdate": "2147-10-27 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1044458, "text": " 8:48 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for aspiration or other lung pathology.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with hcv cirrhosis with code blue, assess for aspiration.\n REASON FOR THIS EXAMINATION:\n assess for aspiration or other lung pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe cirrhosis, recent code blue. Assess aspiration.\n\n COMPARISON: Chest radiographs from and .\n\n TECHNIQUE: MDCT of the chest was performed without intravenous contrast.\n Images were displayed in axial, coronal and sagittal sections including thin\n axial sections.\n\n FINDINGS: The endotracheal tube continues to terminate at the level of the\n carina, and should be pulled back for more appropriate placement. In\n addition, the endotracheal tube cuff is hyperinflated. A nasogastric tube tip\n extends below the hemidiaphragm.\n\n The study is limited by motion. The patient is in the expiratory phase. There\n is narrowing of the bronchus intermedius to approximately 2 mm in diameter. In\n addition, the lower lobe segmental and subsegmental bronchi appear collapsed.\n There is air trapping in the lower lobes bilaterally, which appear hyperlucent\n on this study.\n\n There is centrilobular emphysematous change noted in the upper lobes which is\n mild. Ground-glass opacity diffusely in the upper lobes is compatible with\n the expiratory phase. There is no evidence of consolidation. There is a tiny\n right-sided pleural effusion. There is no pericardial effusion.\n\n The heart, pericardium, and great vessels appear normal in caliber and\n configuration given the non-contrast study.\n\n In the upper abdomen there is extensive ascites. The liver is nodular and\n shrunken. There is splenomegaly measuring up to 14.5 cm. Note is made of\n gynecomastia. There is minimal subcutaneous fat compatible with cachexia.\n\n IMPRESSION:\n\n 1. No evidence of aspiration or pneumonia.\n\n 2. Findings suggestive of bronchomalacia with narrowing of the bronchus\n intermedius as well as collapse of lower lobe subsegmental branches with\n associated air trapping on expiration.\n\n 3. Small right-sided pleural effusion.\n\n (Over)\n\n 8:48 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for aspiration or other lung pathology.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Extensive ascites and findings compatible with cirrhosis as above.\n\n 5. Endotracheal tube at the carina. Cuff overinflated. This was discussed\n with Dr. .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044794, "text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for progression of infiltrate.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis with respiratory failure, now s/p extubation.\n REASON FOR THIS EXAMINATION:\n assess for progression of infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Respiratory failure, extubation.\n\n One view. Comparison with . There is mild blurring consistent with\n motion artifact. The lungs appear otherwise clear. The heart and mediastinal\n structures are unremarkable in appearance as before. A nasogastric tube\n remains in place.\n\n IMPRESSION: No active pulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044110, "text": " 1:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EValuate for infiltrate/ET tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with ET tube s/p liver failure\n REASON FOR THIS EXAMINATION:\n EValuate for infiltrate/ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with endotracheal tube placement status post liver\n failure, to assess for the position.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with radiograph of .\n\n FINDINGS:\n\n The tip of the ET tube is approximately 14 mm from the carina and may need to\n be repositioned. The NG tube needs to be advanced further.\n\n The lungs are of low volume, most likely due to poor inspiratory effort. The\n cardiomediastinal silhouette is stable. There are no focal pulmonary\n consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1046180, "text": " 10:58 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for mechanical obstruction, perforation, other intraa\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, abd pain, at least partial SBO by KUB.\n REASON FOR THIS EXAMINATION:\n assess for mechanical obstruction, perforation, other intraabdominal pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj SUN 7:38 PM\n No evidence of small-bowel obstruction. Large volume of abdominal ascites.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen and pelvis.\n\n HISTORY: 41-year-old male with cirrhosis and abdominal pain. Concern for\n partial small-bowel obstruction.\n\n COMPARISONS: CT on .\n\n TECHNIQUE: Following the administration of oral and intravenous contrast,\n MDCT axial images were acquired from the lung bases to the pubic symphysis.\n Coronal and sagittal reformatted images were then obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are clear. A large volume\n of intra-abdominal ascites somewhat limits detailed evaluation of the intra-\n abdominal organs. The liver is shrunken and nodular in contour compatible\n with history of cirrhosis. Multiple gallstones are identified in a distended\n gallbladder. The pancreas and adrenal glands are unremarkable. The spleen is\n prominent measuring up to 11.6 cm in coronal diameter. There are numerous\n perisplenic and perigastric varices. The kidneys are unremarkable\n bilaterally. The stomach is not distended. There are no distended loops of\n small bowel. Mild wall thickening of jejunal loops in the lower abdomen is\n evident. There is no free intra-abdominal air.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid colon are\n unremarkable. A Foley balloon is present within a collapsed bladder. The\n prostate appears within normal limits. A large volume of pelvic ascites is\n evident.\n\n IMPRESSION:\n\n 1. No evidence of small-bowel obstruction. Possible mild wall thickening of\n jejunal loops in the low-to-mid abdomen, which may relate to ascites or low\n protein state.\n\n 2. Large volume of abdominal and pelvic ascites.\n\n 3. Cholecystitis without evidence of acute cholecystitis.\n\n 4. Shrunken nodular liver with evidence of portal hypertension including a\n (Over)\n\n 10:58 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for mechanical obstruction, perforation, other intraa\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mildly prominent spleen and perisplenic and perigastric varices.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1046181, "text": ", B. MED CCU 10:58 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for mechanical obstruction, perforation, other intraa\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis, abd pain, at least partial SBO by KUB.\n REASON FOR THIS EXAMINATION:\n assess for mechanical obstruction, perforation, other intraabdominal pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of small-bowel obstruction. Large volume of abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2147-10-26 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1044351, "text": " 5:24 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please perform focused RUQ USN to evaluate for cholecytis.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with rising TBIL, s/p RUQ USN yesterday, with ?stone at neck of\n gallbladder, now with rising WBC count, ?infection, please perform focused RUQ\n USN to evaluate for cholecytis.\n REASON FOR THIS EXAMINATION:\n please perform focused RUQ USN to evaluate for cholecytis.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:34 PM\n PFI: Persistent gallstones in collapsed, gallbladder with a thickened wall.\n No intra- or extra-hepatic biliary dilatation. No change compared to\n examination 24 hours prior.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver/gallbladder ultrasound\n\n HISTORY: 41-year-old male with rising total bilirubin and white blood cell\n count. Assess for infection.\n\n COMPARISONS: Ultrasound .\n\n FINDINGS: The liver is shrunken and nodular in contour compatible with\n history of cirrhosis. There is a large amount of abdominal ascites, unchanged\n compared to the study from one day prior. No intra- or extra-hepatic biliary\n dilatation noted. The gallbladder is collapsed and the wall again is noted to\n be relatively thickened. Multiple shadowing echogenic foci fill the\n gallbladder and potentially the gallbladder neck and are compatible with\n gallstones. Overall, this has not changed compared to the study 24 hours\n prior. The common bile duct is not dilated and measures 2 mm in diameter.\n\n IMPRESSION:\n 1. Unchanged cirrhotic shrunken liver.\n 2. Unchanged large volume of ascites.\n 3. Persistent, thickened, collapsed gallbladder with multiple stones. No\n evidence of intra- or extra-hepatic biliary dilatation.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-26 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1044352, "text": ", MED FA10 5:24 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please perform focused RUQ USN to evaluate for cholecytis.\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with rising TBIL, s/p RUQ USN yesterday, with ?stone at neck of\n gallbladder, now with rising WBC count, ?infection, please perform focused RUQ\n USN to evaluate for cholecytis.\n REASON FOR THIS EXAMINATION:\n please perform focused RUQ USN to evaluate for cholecytis.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistent gallstones in collapsed, gallbladder with a thickened wall.\n No intra- or extra-hepatic biliary dilatation. No change compared to\n examination 24 hours prior.\n\n" }, { "category": "Radiology", "chartdate": "2147-10-25 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1044121, "text": " 2:00 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Evaluate for stone/inflammation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with altered MS and ? liver failure\n REASON FOR THIS EXAMINATION:\n Evaluate for stone/inflammation\n ______________________________________________________________________________\n WET READ: JKSd WED 3:00 PM\n Collapsed gallbladder with multiple small stones. Marked ascites and shruken,\n cirrhotic liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with altered mental status and question of liver\n failure. Evaluate for stone/inflammation.\n\n COMPARISON: CT of the abdomen and pelvis of .\n\n TECHNIQUE: Ultrasound of the liver and gallbladder.\n\n FINDINGS: Limited evaluation due to patient's marked ascites and liver\n disease. The liver is shrunken and echogenic with a nodular contour consistent\n with the patient's known history of cirrhosis. The pancreas is not visualized.\n The gallbladder appears collapsed with a thickened wall. Multiple echogenic\n foci seen within are consistent with shadowing calcified gallstones as\n previously described on prior CT. A stone may possibly be within the\n gallbladder neck. No inhepatic bilary ductal dilation is seen. The common bile\n duct is not completely assessed but proximally measures 3mm. The portal vein\n is patent with hepatopetal flow.\n\n A spot was marked for paracentesis in the left lower quadrant.\n\n IMPRESSION:\n Limited study due to marked ascites.\n 1. Cirrhotic, shrunken liver.\n 2. Thickened, collapsed gallbladder with multiple shadowing echogenic foci\n consistent with calcified gallstones. Possible stone within the neck.\n\n" }, { "category": "Radiology", "chartdate": "2147-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046963, "text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with non responsive\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, nasogastric tube is in\n unchanged position. The endotracheal tube could have been slightly advanced,\n its tip now projects 1.5 cm above the carina. Unchanged appearance of the\n cardiac silhouette and of the hila, no signs of overhydration or a focal\n parenchymal opacity suggestive of pneumonia. Overall, the lung volumes are\n slightly bigger than on the previous examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1047163, "text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary infiltrate progression\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with esld, cirrhosis, with respiratory failure.\n REASON FOR THIS EXAMINATION:\n assess for pulmonary infiltrate progression\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 12:07 PM\n PFI: No signs of acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 41-year-old man with ESLD, cirrhosis, with respiratory\n failure. Assess for pulmonary infiltrate progression.\n\n Since yesterday, ETT tip ends 3.2 cm above the carina. Nasogastric tube ends\n in the stomach. Lungs are clear. The cardiomediastinal silhouette and hilar\n contours are normal. There is no pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1047164, "text": ", F. MED MICU-7 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary infiltrate progression\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with esld, cirrhosis, with respiratory failure.\n REASON FOR THIS EXAMINATION:\n assess for pulmonary infiltrate progression\n ______________________________________________________________________________\n PFI REPORT\n PFI: No signs of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-15 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1048049, "text": " 7:21 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: evaluate for portal vein thrombosis\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with ESRD, encephalopathy and altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for portal vein thrombosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 11:48 AM\n Patent hepatic vasculature. Large volume ascites. Cirrhotic liver without\n focal lesions. Cholelithiasis. Splenomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER QUADRANT SON:\n\n INDICATION: 41-year-old man with end-stage renal disease, encephalopathy.\n\n COMPARISON: .\n\n FINDINGS: The liver remains shrunken and nodular in contour, coarse in\n architecture, consistent with cirrhosis. Again noted is a large amount of\n abdominal ascites. There is no intra or extrahepatic biliary ductal\n dilatation. Multiple gallstones fill the gallbladder. There is no intra or\n extrahepatic biliary ductal dilatation. The common duct measures 4 mm at the\n porta hepatis.\n\n LIVER DOPPLER: The main, right and left portal veins are patent with normal\n wall-to-wall hepatopetal flow. The main, left and the right hepatic veins are\n patent. Normal flow and waveforms are noted in the main hepatic artery.\n\n The spleen is enlarged, measuring 14 cm.\n\n IMPRESSION:\n 1. Findings consistent with liver cirrhosis, no focal lesion.\n\n 2. Patent hepatic vasculature.\n\n 3. Cholelithiasis.\n\n 4. Splenomegaly.\n\n 5. Large abdominal ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-11-15 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1048050, "text": ", R. MED SICU-A 7:21 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: evaluate for portal vein thrombosis\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with ESRD, encephalopathy and altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for portal vein thrombosis\n ______________________________________________________________________________\n PFI REPORT\n Patent hepatic vasculature. Large volume ascites. Cirrhotic liver without\n focal lesions. Cholelithiasis. Splenomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2147-11-05 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 1046137, "text": " 6:09 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: please assess for bowel dilatation, free air, other intraabd\n Admitting Diagnosis: ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with cirrhosis and ascites, c/o abdominal discomfort and\n inability to stool.\n REASON FOR THIS EXAMINATION:\n please assess for bowel dilatation, free air, other intraabdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with cirrhosis and ascites, complaining of\n abdominal discomfort and inability to stool. Assess for bowel dilation, free\n air, or other intra-abdominal pathology.\n\n COMPARISON: Supine view of the abdomen and CT abdomen and pelvis\n .\n\n PORTABLE SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN: There are air-distended\n loops of bowel centrally, difficult to definitively determine whether these\n are small bowel or colon. On upright view, there are multiple air-fluid\n levels. No subdiaphragmatic free air is identified.\n\n IMPRESSION: Dilated loops of bowel centrally, with multiple air-fluid levels\n on upright view.\n CT of the abdomen and pelvis would be helpful to further evaluate for\n obstruction or ileus and to evaluate for intraperitoneal free air. Findings\n were discussed with Dr. on at 7:45 a.m.\n\n" }, { "category": "ECG", "chartdate": "2147-11-03 00:00:00.000", "description": "Report", "row_id": 213441, "text": "Sinus rhythm. Non-specific ST-T wave changes in the lateral leads. Compared\nto the previous tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2147-10-27 00:00:00.000", "description": "Report", "row_id": 213442, "text": "Sinus tachycardia. Non-diagnostic inferior Q waves. Since the previous\ntracing of the rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2147-10-25 00:00:00.000", "description": "Report", "row_id": 213443, "text": "Sinus rhythm. Non-specific inferolateral T wave flattening. Compared to the\nprevious tracing of T waves are more prominent in lead V5-V6.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2165-07-16 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1138597, "text": " 3:59 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: RT-ABD PAIN, VOMITING. ? ACUTE PROCESS.\n Field of view: 40 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with vomiting, BRBPR, R-sided abd pain.\n REASON FOR THIS EXAMINATION:\n ? acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 9:50 PM\n 1. Rectum with wall thickening and edematous appearance extending to\n rectosigmoid is concerning for colitis (infectious or inflammatory).\n 2. The remainder of the bowel appears collapsed and therefore difficult to\n evaluate if this extends to other parts of the colon.\n 3. Gallstone.\n 4.Free pelvic fluid.\n 5. Uterine fibroid.\n d/w Dr. at 9:49pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with vomiting and bright red blood per rectum.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the abdomen and\n pelvis with the administration of IV contrast. Multiplanar reformatted images\n (axial, coronal, sagittal) were generated and reviewed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN: Minimal left basilar atelectasis identified. The\n visualized heart and pericardium are unremarkable. There is no evidence of\n bilateral pleural effusion.\n\n The liver is without evidence of focal lesions. The gallbladder shows a\n calcified gallstone. The spleen, pancreas, and bilateral adrenal glands are\n unremarkable. Both kidneys enhance and excrete contrast symmetrically with no\n hydronephrosis or stones. Intra-abdominal loops of small bowel are\n unremarkable.\n\n There is no free fluid or free air within the abdomen. The mesenteric and\n retroperitoneal lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n\n CT OF THE PELVIS: Uterus shows evidence of fibroids, with the largest in the\n fundus measuring 4.1 cm. A ruptured right corpus luteal cyst is present, and\n there is a trace amount of free pelvic fluid. The rectal wall looks thickened\n and edematous, with suggestion of mural edema extending to involve the\n rectosigmoid junction. Findings are concerning for infectious or inflammatory\n proctitis. The remaining large bowel demonstrates mild wall thickening, but\n this may be due to underdistention.\n (Over)\n\n 3:59 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: RT-ABD PAIN, VOMITING. ? ACUTE PROCESS.\n Field of view: 40 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES AND SOFT TISSUES: There is no lytic or sclerotic osseous\n abnormality. A nerve stimulator device is seen in the right abdomen.\n\n IMPRESSION:\n 1. Rectal wall thickening and edema extending to involve the rectosigmoid\n junction, concerning for infectious or inflammatory proctitis. The remainder\n of the colonic wall appears mildly thickened which may be due to\n underdistention, but mild diffuse colitis cannot be excluded.\n 2. Uterine fibroids.\n 3. Ruptured right corpus luteal cyst with small amount of pelvic free fluid.\n 4. Cholelithiasis.\n 5. Left-sided basilar atelectasis.\n\n Dr. was notified of the results at 9:36 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2165-07-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1139074, "text": " 3:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for acute process.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with altered level of consciousness this afternoon. History\n of prior CVA's. Witnessed seizure like activity.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MBue FRI 6:11 PM\n PFI:\n 1. No acute intracranial process.\n 2. Stable left parietal occipital encephalomalacia attributed to patient's\n known prior infarct.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old female with altered level of consciousness and witnessed\n seizure-like activity. History of prior CVA. Question acute process.\n\n COMPARISON: .\n\n TECHNIQUE: A non-contrast CT of the head was obtained.\n\n FINDINGS: There is redemonstration of a large area of hypodensity within the\n left parieto-occipital lobe consistent with encephalomalacia unchanged in\n appearance compared to the prior study. The -white matter differentiation\n is otherwise preserved with no evidence of acute infarction. There is no\n intraparenchymal hemorrhage, mass, mass effect, shift of midline structures,\n or extra-axial fluid collections. There is stable ex vacuo dilatation of the\n occipital of the left lateral ventricle secondary to prior infarct, which\n is unchanged in appearance. The ventricles are otherwise unremarkable. The\n calvarium is stable in appearance. The visualized paranasal sinuses are\n clear.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Stable left parietal occipital encephalomalacia consistent with the\n patient's known prior infarct.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1138615, "text": " 6:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with leukocytosis.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis.\n\n COMPARISON: .\n\n AP UPRIGHT VIEW OF THE CHEST: The heart size is normal. The mediastinal and\n hilar contours are within normal limits. The pulmonary vascularity is normal.\n The lungs are clear. No pneumothorax or pleural effusion is present. There\n are no acute osseous findings.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-07-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1139075, "text": ", W. MED 3:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for acute process.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with altered level of consciousness this afternoon. History\n of prior CVA's. Witnessed seizure like activity.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No acute intracranial process.\n 2. Stable left parietal occipital encephalomalacia attributed to patient's\n known prior infarct.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1138859, "text": " 9:59 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess amount of stool, ? obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with pain out of proportion to exam, ? colitis on CT from 2\n days ago\n REASON FOR THIS EXAMINATION:\n please assess amount of stool, ? obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LLTc FRI 12:45 PM\n No evidence of obstruction or colitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pain, out of proportion to examination.\n\n COMPARISON: CT available from .\n\n SUPINE RADIOGRAPH OF THE ABDOMEN: A spinal stimulator is present in the right\n lower quadrant. The bowel gas pattern is within normal limits. No free air\n is seen. Included views of the lower chest are unremarkable.\n\n IMPRESSION: No evidence of obstruction or colitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-07-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1138860, "text": ", E. MED 12R 9:59 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess amount of stool, ? obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with pain out of proportion to exam, ? colitis on CT from 2\n days ago\n REASON FOR THIS EXAMINATION:\n please assess amount of stool, ? obstruction\n ______________________________________________________________________________\n PFI REPORT\n No evidence of obstruction or colitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1139071, "text": " 2:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for cardiopulmonary process.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with respiratory distress this afternoon. Now on O2.\n REASON FOR THIS EXAMINATION:\n Please evaluate for cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with respiratory distress. Please evaluate for\n cardiopulmonary process.\n\n TECHNIQUE:\n Single portable radiograph of the chest was acquired.\n\n COMPARISON:\n Portable chest radiograph from and PA and lateral radiographs\n from . CTA of the chest from .\n\n FINDINGS:\n The lungs are clear, the cardiomediastinal silhouette and hila are normal.\n There is no pleural pathology. There are no acute bony or soft tissue\n abnormalities.\n\n IMPRESSION:\n No acute cardiothoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1138941, "text": " 6:31 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 44yF with recent CT now with worsening abdominal pain\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with history of stroke, paraplegic, now with worsening\n abdominal pain, colitis on CT 2 days ago\n REASON FOR THIS EXAMINATION:\n 44yF with recent CT now with worsening abdominal pain\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:30 PM\n 1. limited as oral contrast has not reached the rectum. Previous\n rectosigmoid wall thickening has improved.\n 2. Cholelithiasis and perichole fluid or wall thickening. These are\n nonspecific findings and cholecystitis can not be excluded based on this scan\n IF concern remains a HIDA scan can be obtained.\n 3. 1.5 cm heterogeneously enhancing soft tissue to the right of anal verge\n (2:79) is stable since . This can be infectious-inflammatory in nature.\n less likely neoplastic. Clinical correlation suggested.\n 4. Grossly stable small to mod free pelvic fluid. No abscess. Fibroid\n uterus. Small bilat pleural effusions with adjacent atx.\n 5. Prominent soft tissue and mild fat strandind adjacent to right ischial\n tuberosity, partially imaged. this can be chronic tendinopathy. pls\n clinically corrlate.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stroke and paraplegia with worsening abdominal pain and question of\n colitis on prior CT.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the abdomen and pelvis performed after administration of\n oral and IV contrast. Multiplanar reformats were performed.\n\n FINDINGS:\n\n ABDOMEN: There are small bilateral pleural effusions and bibasilar\n atelectasis. The liver appears normal. The gallbladder once again\n demonstrates a gallstone as well as some vicarious excretion of contrast.\n There is now diffuse gallbladder wall thickening, but the gallbladder is not\n distended, and they are not prominent inflammatory changes in the surrounding\n fat. There is no biliary dilatation. The pancreas, spleen, adrenal glands,\n and kidneys appear normal. The small bowel loops appear normal.\n\n PELVIS: There is still a moderate amount of free fluid within the pelvis.\n The previously described rectal and sigmoid wall thickening has resolved and\n now appears normal. The uterus demonstrates a probable fibroid towards the\n fundus. Note is made of asymmetric soft tissue in the right ischioanal fossa\n measuring approximately 1.6 cm. No definite low-attenuation fluid collection\n is seen.\n (Over)\n\n 6:31 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 44yF with recent CT now with worsening abdominal pain\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are degenerative changes in the spine. Note is made of an epidural\n catheter.\n\n IMPRESSION:\n\n 1. Resolution of previously noted rectosigmoid wall thickening.\n\n 2. Stable moderate amount of free fluid in the pelvis.\n\n 3. Cholelithiasis. There is now diffuse non-specific gallbladder wall edema,\n but the CT appearance of the gallbladder does not suggest acute inflammatory\n process.\n\n 4. Asymmetric soft tissue in the right ischioanal fossa. Possibilities would\n include a perianal fistula or abscess. Direct visualization of this region\n recommended.\n\n 5. Small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-19 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1139042, "text": "GALLBLADDER SCAN Clip # \n Reason: 44YR OLD W/ACUTE ABDOMINAL PAIN EVAL FOR FILLING OF THE GALLBLADDER\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 3.9 mCi Tc-m DISIDA ();\n HISTORY: 44 year old female with abdominal pain.\n\n The 3.9 mCi of Tc-m DISIDA was injected, however due to medical emergency the\n images could not be obtained.\n\n\n\n\n\n\n , M.D.\n , M.D. Approved: MON 2:21 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": "2165-07-22 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1139453, "text": "GALLBLADDER SCAN Clip # \n Reason: 44 Y/O WOMAN WITH PROBABLE ACUTE CHOLECYSTITIS, ASSESS FOR BILIARY DRAINAGE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 4.4 mCi Tc-m DISIDA ();\n HISTORY: Abdominal pain with question of acute cholecystitis.\n\n INTERPRETATION: Serial images over the abdomen show uptake of tracer into the\n hepatic parenchyma. At 18 minutes, the gallbladder is visualized with tracer\n activity noted in the small bowel at 53 minutes.\n\n IMPRESSION: Normal study\n\n Results discussed via telephone at 15:55 with Dr. \n\n\n\n , M.D.\n , M.D. Approved: TUE 3:24 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": "2165-07-19 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1139050, "text": " 1:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for acute cholecystitis\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with history of stroke with resulting weakness, now with\n diffuse abdominal pain, occasionally worse in RUQ\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute cholecystitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ETz FRI 5:57 PM\n Single gallstone within the gallbladder. The gallbladder is not particularly\n distended and is less distended than on the CT dated . There is\n gallbladder wall thickening and the patient is tender over the location of the\n gallbladder. In the correct clinical setting these findings could be due to\n acute cholecystitis. Correlation with HIDA scan would be helpful to further\n evaluate for acute cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with history of stroke with resulting weakness,\n now with diffuse abdominal pain occasionally worse in right upper quadrant.\n Evaluate for acute cholecystitis.\n\n FINDINGS:\n\n The liver is normal in size and echogenicity with no focal abnormality. There\n is no intrahepatic bile duct dilatation.\n\n A single gallstone is seen within the gallbladder. The gallbladder is not\n distended, and is even less distended than on the CT dated . The\n gallbladder wall is thickened measuring up to 6 mm. No pericholecystic fluid\n is present. The patient was very tender at the site overlying the\n gallbladder.\n\n CONCLUSION: Single gallstone within the gallbladder. The gallbladder is less\n distended than on the CT dated . There is gallbladder wall\n thickening and the patient is tender over the gallbladder. In the correct\n clinical setting these findings could be due to acute cholecystitis.\n Correlation with a HIDA scan would be helpful to further evaluate for acute\n cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-19 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1139051, "text": ", E. MED 12R 1:06 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please evaluate for acute cholecystitis\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with history of stroke with resulting weakness, now with\n diffuse abdominal pain, occasionally worse in RUQ\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute cholecystitis\n ______________________________________________________________________________\n PFI REPORT\n Single gallstone within the gallbladder. The gallbladder is not particularly\n distended and is less distended than on the CT dated . There is\n gallbladder wall thickening and the patient is tender over the location of the\n gallbladder. In the correct clinical setting these findings could be due to\n acute cholecystitis. Correlation with HIDA scan would be helpful to further\n evaluate for acute cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2165-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140048, "text": " 2:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 44 year old woman with low grade fever and cough, eval for i\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with low grade fever and cough, eval for infiltrate\n REASON FOR THIS EXAMINATION:\n 44 year old woman with low grade fever and cough, eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 44-year-old female patient with low-grade fever and cough.\n Evaluate for infiltrate.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n upright position. Comparison is made with the next previous similar study of\n . No significant interval change can be identified. Heart size\n is within normal limits. Thoracic aorta unremarkable. No mediastinal\n abnormalities. Pulmonary vasculature normal. No signs of acute infiltrates.\n\n Stable normal chest findings. Previous chest examinations are also reviewed\n including a chest CT from . The latter examination disclosed an\n isolated mildly enlarged right-sided hilar lymph node which cannot be expected\n to be seen on plain chest x-ray. No other abnormalities were identified on\n the CT. For detail, see corresponding report.\n\n IMPRESSION: Stable chest findings. No evidence of new acute infiltrates in\n patient with low-grade fever and cough.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2140-04-13 00:00:00.000", "description": "Report", "row_id": 1507172, "text": "NEURO ALERT ORIENTED NO WEAKNESS NOTED NEURO INTACT FOLLOWS COMMANDS ANSWERS APPROPRIATLY STATES HE SEES NUMBERS ON A SCREEN IN FRONT OF HIM NO OTHER SIGNS OF CONFUSION NOTED MD AWARE IN TO EVALUATE C/O SLIGHT H/A AFTER IN AM TYLENOL WITH RELIEF\n\nC/V NSR RARE PAC B/P STABLE WEANING NICARPINE PO SULAR STARTED TOL WELL B/P 130/50 OF IV MEDS GOOD PEDAL PULSES\n\nRESP RA SATS 95% LUNGS CLEAR NO SOB OR DISTRESS\n\nGU/GI TOL PO WELL SOFT DIET STARTED LOW U/O ABD SOFT BOWEL SOUNDS HEARD\n\nPLAN CONTINUE TO ASSESS NEURO STATUS POSSIBLE TRANSFER IF REMAINS STABLE\n" }, { "category": "Nursing/other", "chartdate": "2140-04-12 00:00:00.000", "description": "Report", "row_id": 1507169, "text": "NEURO ALERT ORIENTED X3 NEUROS INTACT PUPILS EQUAL AND REACTIVE C/O ONLY OF SLIGHT H/A\n\nC/V NSR WITH NODAL HR 40S AT TIMES WITH STRAINING TO VOID MD AWARE B/P ELEVATED ALINE 190S WITH CUFF IN 130S FLING NOTED IN ALINE TRACE DR AWARE TITRATED NIPRIDE TO CUFF TEAM EVAL TO CHANGE NIPRIDE TO NICARDIPINE AFTER RETURN FROM RADIOLOGY GOOD PALP PULSES\n\nRESP RA SATS 97-99% LUNGS CLEAR NONPRODUCTIVE\n\nGU/GI SOME STRAINING WITH URINE FOLEY PLACED PRE MD WITH 425CC CLEAR RETURN ABD SOFT NPO\n\nPLAN CONTINUE TO MONITOR B/P AND MAINTAIN WITH NIPRIDE/NICARDIPINE\n" }, { "category": "Nursing/other", "chartdate": "2140-04-12 00:00:00.000", "description": "Report", "row_id": 1507170, "text": "NEURO ALERT AND ORIENTED SLIGHT VAGUE AND RESTLESS ON RETURN FROM ANGIO EQUAL STRENGHTS PUPIL EQUAL AND REACTIVE C/O SLIGHT H/A\n\nC/V NSR WITH PACS ON ARRIVAL FROM RADIOLOGY MD 2.5MG WITH GOOD EFFECT DECREASED PACS B/P REMAINS ELEVATED WITH NIPRIDE WEANING TO OFF AND NICARDIPINE TITRATED UP HYDRALAZINE GIVEN WITH CUFF B/P 130S SYSTOLIC ALINE 150-180SYSTOLIC MD AWARE OF DIFFERENCE FOLLOWING ALINE TX CUFF GOOD PEDAL PULSES\n\nRESP RA SATS 96 PRIOR TO SOME INCREASED LETHARGY POST NC 2L ON WITH SATS INCREASED FROM 93% TO 96% LUNGS CLEAR DIMINISHED BASES NO SOB OR RESP DISTRESS\n\nGU/GI ABD SOFT BOWEL SOUNDS FAINT VOMITTED X2 ON RETURN FROM ANGIO AND NICARDIPINE STARTED MD GIVEN WITH GOOD EFFECT 1800 TAKING SIPS WITH MEDS TOL WELL\n\nXRAY TO INTERVENTIONAL RADIOLOGY FOR ARTERIOGRAM 930AM RETURN 130PM SHEATH PULLED R GROIN 130PM PRESSURE DSG APPLIED NO BLEEDING CHECKED Q15MIN REMAINS BEDREST LEG IMMOBILIZED X5HOURS MD /MRA TONOC\n\nPLAN CONTINUE TO MONITOR B/P AND MAINTAIN WITH CURRENT MEDS EVALUATE NEURO STATUS\n" }, { "category": "Nursing/other", "chartdate": "2140-04-13 00:00:00.000", "description": "Report", "row_id": 1507171, "text": " UPDATE\nPT SCHEDULED FOR OF HEAD EARLIER IN SHIFT. AT THIS TIME, PT WAS AGITATED AND PULLING THINGS OFF OF HIM. ORIENTED ONLY TO PERSON AND PRESENTED WITH NEW SLIGHT RIGHT FACIAL DROOP. FELT PT WOULD NOT STAY STILL FOR EXAM. ASKED T/SICU RESIDENT FOR SEDATION ORDERS, HOWEVER, PTS DAUGHTER REFUSED ANY SEDATION ORDERS UNLESS IT WENT DIRECTLY THROUGH DR. . WAS UNABLE TO GET IN TOUCH WITH DR. DESPITE SEVERAL CALLS TO PAGER AS WELL AS ANSWERING SERVICE WHICH WAS BUSY WITH EACH TRY. AROUND 2300, DR. CALLED THE UNIT TO REPORT THE FAMILY HAD CALLED HIM AT HOME WITH THIS INFORMATION. DURING THIS PERIOD, THE PT HAD BEEN EXAMINED BY THE T/SICU RESIDENT WHO CALLED THE FAMILY TO REITERATE THE IMPORTANCE OF THE EXAM AND THE POSSIBILITY OF GIVING SEDATIVES. DR. CAME IN TO SEE THE PATIENT AROUND MIDNOC AND FELT THE FINDINGS DID NOT DEEM NECESSARY A STAT CT SCAN AND THE COULD WAIT UNTIL MORNING. PT HAS BEEN ORIENTED X 3 THROUGHOUT THE REMAINDER OF THE SHIFT. CONTINUES WITH SLIGHT RIGHT FACIAL DROOP AND INTERMITTENT RIGHT PRONATOR DRIFT. O/W, NEURO INTACT. SYSTEMS REVIEW WNL.\nPLAN: TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-12 00:00:00.000", "description": "Report", "row_id": 1507168, "text": "adm note\nO: Adm from EW w recent onset severe headache. Ct scan + intraventric hemorrhage. Pt scheduled for mri and ct angiogram in am.\nAdm from EW on snp at 0.5 mcg/kg/m titrating for goal sbp 130-150.Cuff and art line not consistently correlating.\nNeuro status: c/o headache. nvs stable. perl @ 3mm brisk reactive. Speech clear.No apparent motor deficits.Pleasant,conversant gentleman only complaint is headache currently -> 2 tabs tylenol po.\n\nCv status: sr w 1 avb w labile htn controlling w snp.Distal pulses+ by palp.\n\nResp status: sats 99% on rm air bbs clear.\nNormal resp pattern\n\nGi status: abd soft,+ bowel snds.Npo for ct angio & mri in am.\n\nGu status: vded cl yellow urine\n\nIv access: rt upper arm slock. lt lower arm 18gauge d51/2s w 20kcl @125cc/hr. Rt rad art line transd.\n\nA/P: npo for ct angio and mri in am. neuro vs . titrate snp for sys bp goal 130-150\n" }, { "category": "Radiology", "chartdate": "2140-04-13 00:00:00.000", "description": "MR-ANGIO HEAD", "row_id": 821446, "text": " 8:56 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: pls do mri/mra\n Admitting Diagnosis: INTRAVENTRICULAR BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with headache, blood layering in ventricles on CT\n REASON FOR THIS EXAMINATION:\n pls do mri/mra\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Headaches, blood layering in ventricles on CT.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained\n without IV contrast. MRA of the circle of .\n\n Comparison with prior cerebral angiogram and head CT's from and , .\n\n MRI OF THE BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are\n slightly prominent, likely related to patient's age and not changed compared\n to the prior study from . Again seen is a small amount of\n layering blood within the posterior horns of the lateral ventricles. On\n susceptibility images bilateral subarachnoid hemorrhage is also noted, which\n was not evident on the prior non-contrast head CT. There are areas of high T2\n signal in the periventricular white matter suggestive of small vessel ischemic\n disease. There are no subdural collections.\n\n MRA OF THE CIRCLE OF : There is fullness in the supraclinoid portion of\n the right internal carotid artery just beyond a mild degree of stenosis,\n findings which may be related to post- stenotic dilatation- there is no\n discrete aneurysm. There is a tiny, 2 mm aneurysm in the left posterior\n communicating artery, near the origin from the internal carotid artery. There\n is diffuse atherosclerosis of the left vertebral artery.\n\n IMPRESSION: 1) Subarachnoid hemorrhage in bilateral sylvian fissures and\n stable bilateral interventricular hemorrhage. The size of the lateral\n ventricles remain stable compared to prior study.\n\n 2) 2 mm aneurysm in the left posterior communicating artery.\n\n 3) Probable post-stenotic dilatation of the right supraclinoid internal\n carotid artery.\n\n 4) Small vessel ischemic disease. Findings were discussed with Dr. \n at the time of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-14 00:00:00.000", "description": "ADD'L 2ND/3RD ORDER", "row_id": 821562, "text": " 10:39 AM\n CAROT/CEREB Clip # \n Reason: ?ANEURYSM\n Admitting Diagnosis: INTRAVENTRICULAR BLEED\n Contrast: OPTIRAY Amt: 200\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL UNILAT CAROTID/CEREBRAL UNILAT *\n * VERT/CAROTID A-GRAM C1769 GUID WIRES INFU/PERF *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n History of subarachnoid hemorrhage. The patient had a previous angiogram on\n the previous day. The patient was moving and it was difficult to catheterize\n the right internal and right vertebral arteries at the time. Hence the patient\n was brought back and the present angiogram was performed under general\n anesthesia.\n\n TECHNIQUE:\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications and alternative management. Risks explained\n included stroke, loss of vision and speech, temporary or permanent, with\n possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following blood vessels were selectively catherized, and arteriograms were\n performed from these locations: right common carotid artery, right internal\n carotid artery, right vertebral artery.\n\n Please note that the previous dicatation has been lost in the process of\n transcription. This is a redictation.\n\n RIGHT COMMON CAROTID ARTERY:\n No significant atherosclerotic disease noted.\n\n RIGHT INTERNAL CAROTID ARTERY:\n There is good opacification of the proximal and distal right internal carotid\n artery, anterior and middle cerebral artery branches. There is an irregular\n aneurysm noted arising from the posterior communicating artery and measures\n approximately 10 x 6 x 4 mm in size. This appears to be the source of the\n (Over)\n\n 10:39 AM\n CAROT/CEREB Clip # \n Reason: ?ANEURYSM\n Admitting Diagnosis: INTRAVENTRICULAR BLEED\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage.\n\n RIGHT VERTEBRAL ARTERY:\n There is good opacification of the proximal and distal right vertebral artery,\n basilar artery and posterior cerebral artery on both sides. No definite\n aneurysm noted.\n\n IMPRESSION:\n Irregular aneurysm measuring approximately 10 x 6 x 4 mm in size noted arising\n at the origin of the right posterior communcating artery. This appears to be\n the source of the hemorrhage.\n\n These findings were immediately discussed with Dr. , the referring\n neurosurgeon.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-11 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 821301, "text": " 9:57 PM\n CT HEAD W/ CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: soure of intraventricular hemorrhage?need ct angiogram\n Field of view: 27 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n soure of intraventricular hemorrhage?need ct angiogram\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: History of intraventricular hemorrhage. To rule out\n aneurysm.\n\n CT angiogram of the circle of was performed.\n\n FINDINGS: There is good flow noted in the anterior and posterior circulation.\n The intracranial vessels are extremely tortuous which limits the evaluation.\n There is questionable rounded density noted at the right posterior\n communicating artery region and also at the basilar tip region. A small\n aneurysm cannot be totally excluded.\n\n IMPRESSION: Study limited secondary to extremely tortuous vessels. There is\n evidence of questionable aneurysm at the right posterior communicating artery\n or basilar tip. A conventional angiogram is recommended for further\n evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-12 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 821336, "text": " 9:07 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Admitting Diagnosis: INTRAVENTRICULAR BLEED\n Contrast: OPTIRAY Amt: 295\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL UNILAT *\n * CAROTID/CEREBRAL UNILAT VERT/CAROTID A-GRAM *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n Please note that this is a redictation. The previous dictation has been lost\n during the process of transcription.\n\n CLINICAL HISTORY:\n 86-year-old male with a subarachnoid hemorrhage along the Sylvian fissures\n bilaterally and small intraventricular hemorrhage in the occipital horns\n bilaterally.\n\n TECHNIQUE:\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications and alternative management. Risks explained\n included stroke, loss of vision and speech, temporary or permanent, with\n possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following blood vessels were selectively catherized, and arteriograms were\n performed from these locations: left common carotid artery, left internal\n carotid artery, left subclavian artery, left vertebral artery.\n\n LEFT COMMON CAROTID ARTERY:\n No significant atherosclerotic disease noted.\n\n LEFT INTERNAL CAROTID ARTERY:\n There is good opacification of the left proximal and distal left internal\n carotid artery, anterior and middle cerebral artery branches. There is a small\n aneurysm measuring approximately 2.5 mm in diameter with a wide neck and\n appears to arise at the origin of the posterior communicating artery.\n\n LEFT VERTBRAL ARTERY:\n (Over)\n\n 9:07 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Admitting Diagnosis: INTRAVENTRICULAR BLEED\n Contrast: OPTIRAY Amt: 295\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is minimal narrowing noted at the origin of the left vertebral artery.\n There is good opacification of the proximal and distal left vertebral artery,\n basilar artery and posterior cerebral arteries on both sides.\n\n The right internal carotid artery and the right vertebral artery could not be\n catheterized secondary to severe tortuosity of the vessels and the patient's\n breathing. The patient will be brought back for re-angiogram of these vessels\n under general anesthesia.\n\n IMPRESSION:\n A 3.5 mm aneurysm with wide neck is noted at th origin of the left posterior\n communicating artery.\n\n These findings were immediately discussed with Dr. , the referring\n neurosurgeon after the examination.\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2140-04-11 00:00:00.000", "description": "Report", "row_id": 259075, "text": "Sinus rhythm. First degree A-V delay. Consider left atrial abnormality. Left\nventricular hypertrophy by voltage. Modest non-specific low amplitude lateral\nT wave changes. Since the previous tracing of T wave morphology now\nindicative of sinus mechanism rather than ectopic focus.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2187-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176011, "text": " 7:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman ao-carotid-subclav BPG and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n WET READ: IPf TUE 8:46 PM\n Right PICC tip projecting at the mid SVC.\n Left CT removed; no large PTX.\n Othervise, no significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Carotid subclavian bypass surgery, removal of chest tube.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, two chest tubes have been\n removed. There is no evidence of pneumothorax.\n\n Unchanged moderate cardiomegaly with mild pulmonary edema. Bilateral areas of\n atelectasis, left more than right. The presence of minimal pleural effusions\n cannot be excluded. Unchanged right PICC line. No newly appeared focal\n parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-02 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1175461, "text": " 6:12 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman coronary artery disease\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n WET READ: OXZa SAT 1:11 AM\n No evidence of acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation.\n\n TECHNIQUE: Two views of the chest.\n\n COMPARISON: None available.\n\n FINDINGS: The lungs are fully expanded and clear. No pleural effusion,\n pulmonary edema, or pneumothorax is present. The heart, mediastinal and\n pleural surface contours are normal. Incidental note is made of an abnormally\n elevated and rotated left scapula, which may represent a winged scapula\n\n IMPRESSION: No evidence of acute cardiopulmonary process. Abnormal\n configuration of left scapula, likely congenital, ?? winged scapula.\n\n" }, { "category": "Radiology", "chartdate": "2187-02-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1175915, "text": " 10:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check r arm, double lumen PICC. 40 cm\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with s/p carotid\n REASON FOR THIS EXAMINATION:\n check r arm, double lumen PICC. 40 cm\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:21 A.M. ON \n\n HISTORY: Check PIC line.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right PIC line extends approximately 15 mm beyond the tip of the\n wire heading superiorly just above the right clavicle. Whether this is in a\n large or a small saphenous vein is radiographically indeterminate.\n\n Lung volumes are lower today and there may be mild edema in the right lung.\n Mediastinal drains are still in place, and there has been an increase in left\n lower lobe atelectasis and probable small left pleural effusion.\n Cardiomediastinal silhouette is difficult to assess because of patient\n rotation, but there may also be an increase in caliber of mediastinal veins.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-03 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1175553, "text": " 1:42 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: cerebral vasculature for anatomy\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with known occlusion of right innominate artery s/p carotid\n to carotid bypass in past. She is preop for CABG and aorto-innominate artery\n bypass \n REASON FOR THIS EXAMINATION:\n cerebral vasculature for anatomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy SAT 2:38 PM\n CT head: no hemorrhage, edema or mass effect. coils in the region of the\n surpasellar cistern with assoc streak artifact noted.\n\n CTA head and neck:\n\n known right innominate occlusion noted. there is a patent left to right\n carotid graft with distal opacification seen of the right carotid as well as\n the right subclavian, with some retrograde flow into the innominate as well.\n cervical carotids are otherwise both unremarkalbe without flow-limiting\n stenosis. the right and left vertebrals are also widely patent.\n\n intracranially, the COW is patent. there is metallic material noted in the\n suprasellar region, likely reflecting prior aneurym coiling, and limiting\n evaluation of the distal carotid arteries. no residual aneurysms identified.\n the major branches of the anterior and posterior circulation are patent\n without vessel occlusion or stenosis.\n\n nodular left thyroid - rec non-emergent US\n\n final read pending recons\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with occluded innominate artery and carotid\n bypass grafting, now preop for coronary artery bypass grafting and\n aorto-innominate artery bypass surgery for further evaluation. All assessment\n of cerebral vasculature.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this, using departmental protocol, CT angiography of the head and\n neck acquired. There are no prior studies available for comparison.\n\n FINDINGS: HEAD CT:\n\n There is mild brain atrophy seen. No hemorrhage, mass effect, midline shift\n or hydrocephalus identified. The -white matter differentiation is\n maintained. Metallic artifacts are seen in both paraclinoid region which\n (Over)\n\n 1:42 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: cerebral vasculature for anatomy\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n could be secondary to aneurysm coiling, but exact clinical history is not\n available at this time.\n\n CT ANGIOGRAPHY NECK:\n\n CT angiography of the neck demonstrates occlusion of the innominate artery as\n per the clinical history. There is a graft visualized between both carotid\n arteries extending from the left carotid to the right side with a retrograde\n filling of the proximal carotid and innominate artery with filling of the\n subclavian artery. Both vertebral arteries appear patent in the neck with the\n left vertebral artery dominant. The right carotid artery is smaller in size,\n but demonstrates no stenosis or occlusion, bifurcation calcifications are\n noted. The left carotid also demonstrates no evidence of stenosis or\n occlusion. The bifurcations are low in position. Cervical spinal fusion is\n identified which appears congenital in nature extending from C5 inferiorly to\n C7 level. There are laminectomies in the upper cervical region.\n\n CT ANGIOGRAPHY HEAD:\n\n CT angiography of the head demonstrates artifacts limiting evaluation in the\n paraclinoid region for the carotid flow. The supraclinoid carotids are\n identified bilaterally. Both middle cerebral arteries and anterior cerebral\n artery as well as in the region of anterior communicating artery appear normal\n without stenosis, occlusion, or an aneurysm greater than 3 mm in size. In the\n posterior circulation, normal appearance is seen without evidence of stenosis,\n occlusion, or significant atherosclerotic disease. Bilateral posterior\n communicating arteries are visualized, left more prominent than the right\n side.\n\n IMPRESSION:\n 1. No evidence of intracranial hemorrhage, mass effect, or hydrocephalus on\n head CT. Metallic artifacts in both paraclinoid regions, likely from prior\n aneurysm coiling, but clinical correlation recommended.\n 2. CT angiography of the neck demonstrates carotid to carotid bypass graft\n with occluded origin of the innominate artery, but filling of the right\n carotid and right subclavian artery through collateral flow. No carotid\n occlusion or stenosis in the neck with normal vertebral arteries.\n 3. Patent supraclinoid carotid with normal appearance of the anterior and\n posterior circulation arteries with no evidence of stenosis, occlusion, or an\n aneurysm greater than 3 mm in size. Evaluation in the region of coiling is\n limited secondary to artifacts. Both posterior communicating arteries are\n visualized.\n 4. Spinal fusion likely congenital in the lower cervical region with\n laminectomies in the upper cervical region.\n 5. Small thyroid nodule, which can be further evaluated with ultrasound as\n (Over)\n\n 1:42 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: cerebral vasculature for anatomy\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n clinically indicated, located in the left lobe of thyroid.\n\n COMMENT: This report is provided without the availability of 3D reformatted\n images. When these images are available, and if additional information is\n obtained, an addendum will be given to this report.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-03 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1175554, "text": " 1:43 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please evaluate aorta\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with known occlusion of right innominate artery s/p carotid\n to carotid bypass in past. She is preop for CABG and aorto-innominate artery\n bypass \n REASON FOR THIS EXAMINATION:\n Please evaluate aorta\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 45-year-old woman with known occlusion of the right innominate\n artery status post carotid to carotid bypass in the past. Evaluate aorta.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: MDCT images were acquired through the chest with and without IV\n contrast. Multiplanar reformations, volume-rendered images, and curved\n reformats were obtained and reviewed.\n\n The thyroid gland is unremarkable. The carotid to carotid bypass is only\n noted on the non-contrast series. A hypodense nodule is noted in the left\n lobe of the thyroid. There is no axillary or mediastinal lymphadenopathy by\n CT size criteria. The heart and great vessels are unremarkable. No\n pericardial effusions are present.\n\n The visible lungs show mild bibasilar atelectasis, but no worrisome nodules,\n effusions or consolidations are present. There is mild apical centrilobular\n emphysema.\n\n The partially imaged abdomen shows an unremarkable liver, spleen and partially\n imaged pancreas.\n\n VESSELS:\n\n There is a short segment of complete occlusion in the right innominate artery\n with contrast noted within the subclavian artery, possibly filling retrograde\n from the vertebral artery.\n\n IMPRESSION:\n\n 1. Short segment of innominate artery occlusion as noted before. The\n remainder of the thoracic aorta is unremarkable.\n\n 2. Mild centrilobular emphysema.\n\n 3. Small hypodense left thyroid lobe nodule measuring 7 mm may be further\n evaluated with a dedicated thyroid ultrasound as one has not been recently\n obtained.\n (Over)\n\n 1:43 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please evaluate aorta\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2187-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176109, "text": " 11:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, to assess for effusion.\n\n FINDINGS: In comparison with the study of , there is continued moderate\n cardiomegaly with mild pulmonary edema. An area of opacification in the mid\n and lower zone on the left is worrisome for possible aspiration. Central\n catheter remains in place in this patient with intact midline sternal wires.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1175797, "text": " 2:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion - is icu provider, page h\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with s/p Aorto/Inniminate/Carotid Subclavian Bypass/CABG\n - is icu provider, page him if there is concern with\n findings\n REASON FOR THIS EXAMINATION:\n ptx, effusion - is icu provider, page him if there is\n concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post bypass and CABG surgery.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has undergone\n CABG. The sternal wires show correct alignment. The pleural and mediastinal\n drains are in correct position. The tip of the endotracheal tube projects 2.8\n cm above the carina. Moderate retrocardiac atelectasis. No pneumothorax. No\n pulmonary edema. A lucency just inferior to the aortic knob along the left\n heart border could suggest a minimal pneumopericardium.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-06 00:00:00.000", "description": "CVL INJ/EVAL INCLUDES FLUORO/IMAGES/REPORT", "row_id": 1175994, "text": " 3:54 PM\n VENOUS LINE CHECK Clip # \n Reason: PICC goes into neck, please reposition\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ********************************* CPT Codes ********************************\n * CVL INJ/EVAL INCLUDES FLUORO/I *\n * *\n * *\n * *\n * *\n * *\n * *\n * *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with s/p iliac stent, perc trach\n REASON FOR THIS EXAMINATION:\n PICC goes into neck, please reposition\n ______________________________________________________________________________\n FINAL REPORT\n PICC REPOSITION\n\n Prior to the proposed procedure, a spot fluorographic image was taken. The\n tip of the preexisting PICC is seen in the mid SVC. Therefore, the procedure\n was not performed. The PICC is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-02-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1176564, "text": " 10:11 AM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: INNOMINATE OCCLUSION\\AORTO/ INNOMINATE/ CAROTID SUBCLAVIAN BYPASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with Ao-subclavian-Ao- carotid by pass\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VEIWS ON \n\n HISTORY: Bypass, question interval change.\n\n REFERENCE EXAM: .\n\n FINDINGS: Compared to the prior exam, the pulmonary edema is slightly\n improved. There continue to be small bilateral pleural effusions, but the\n alveolar infiltrates have decreased. There continues to be mild cardiomegaly.\n Right-sided central line with tip at the cavoatrial junction is again seen.\n Sternal wires are unchanged.\n\n\n" }, { "category": "ECG", "chartdate": "2187-02-05 00:00:00.000", "description": "Report", "row_id": 199427, "text": "Sinus rhythm. Early R wave progression. Since the previous tracing of \nthe rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2187-02-03 00:00:00.000", "description": "Report", "row_id": 199428, "text": "Sinus rhythm. Normal tracing. No change compared to tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2187-02-02 00:00:00.000", "description": "Report", "row_id": 199662, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2157-10-10 00:00:00.000", "description": "ICU Attending Admit Note", "row_id": 420382, "text": "Clinician: Attending\n Please see Dr note for details of history and presentation. I\n 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 PMH, SH, FH, ROS, assessment and plan.\n Key issues:\n yo man with chronic predominantly diastolic congestive heart failure\n with 4 admissions for CHF since , the two most recent of which\n ( and now) have required ICU care. In early he was on BiPAP\n in MICU, on lasix drip. Brought to ED today because of shortness of\n breath and poor urine output. Found to be hypoxemic to low 80s on 100%\n NRB in ED, tachypneic. Placed on BiPAP in ED with rapid relief of\n symptoms. Also given ceftriaxone/azithro in ED. CXR shows bilateral\n large pleural effusions and PVC, effusions worse since previous\n admission. Lasix given in ED, 100 mg IV, with 100cc out.\n Exam sig for no significant respiratory distress. Tells me his\n breathing is back to baseline. SpO2 100% on face tent 40%. Exam sig\n for: appears comfortable, moderate air movement with dullness at bases,\n + LE edema bilaterally, no abd tenderness.\n Will start lasix drip to optimize his fluid status.\n BiPAP if it becomes necessary.\n Continue carvedilol.\n No indication for starting inotropic support.\n See Dr note for other issues.\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2157-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420381, "text": " YO mult admissions for CHF admitted from facility\n with SOB X 2 days. Per EW report pt reports\n recent wt gain\n. Initially\n sats 80\ns on RA. In EW pt tachypneaic, unable to speak in full\n sentences, pale, +3 pitting edema. CXR\n. temp 95.4. Given lasix\n 20mg /80mg, ceftriaxine, azithro. EKG done, UO 80 CC\ns Transferred\n to 4.\n" }, { "category": "Nursing", "chartdate": "2157-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420383, "text": " YO mult admissions for CHF admitted from facility\n with SOB X 2 days.\n Other PNH sig for CABG in 79, DM, nod pulm HTN, Home O2 ? 2L NP Per EW\n report pt reports\n recent wt gain\n. Initially sats 80\ns on RA. In EW pt\n tachypneaic, unable to speak in full sentences, pale, +3 pitting\n edema. CXR\n. temp 95.4. Given lasix 20mg /80mg, ceftriaxine,\n azithro. EKG done, UO 80 CC\ns Transferred to 4.\n On arrival O2 titrated down to 40% face tent. BS diminished at bases,\n crackles\n up on R. Pt stating his breathing was back to baseline.\n Requesting water\n Son phoned & updated on pt\ns condition. Of note son reports\n increased SOB for past 4-5 months. \ns cell phone # is \n" }, { "category": "Nursing", "chartdate": "2157-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420385, "text": " YO mult admissions for CHF admitted from facility\n with SOB X 2 days.\n Other PNH sig for CABG in 79, DM, nod pulm HTN, Home O2 ? 2L NP Per EW\n report pt reports\n recent wt gain\n. Initially sats 80\ns on RA. In EW pt\n tachypneaic, unable to speak in full sentences, pale, +3 pitting\n edema. CXR\n. temp 95.4. Given lasix 20mg /80mg, ceftriaxine,\n azithro. EKG done, UO 80 CC\ns Transferred to 4.\n On arrival O2 titrated down to 40% face tent. BS diminished at bases,\n crackles\n up on R. Pt stating his breathing was back to baseline.\n Requesting water\n Son phoned & updated on pt\ns condition. Of note son reports\n increased SOB for past 4-5 months. \ns cell phone # is \n" }, { "category": "Nursing", "chartdate": "2157-10-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 420538, "text": " yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who\n presents from his with increased shortness of breath.\n His torsemide dose had recently been increased from 10mg to 20mg daily\n over the weekend given weight gain, poor urinary output and rales on\n exam per visiting nursing. On this dose was increased to 40mg\n daily, however, without substantial benefit and pt was referred to ED\n today for respiratory distress. According to his son, prior to this\n time he had been doing well on the torsemide, however still had very\n poor exercise tolerance and even the smallest task (such as weighing\n himself) causes him to become dyspnea.\n .\n He has had multiple recents admissions for hypoxia and respiratory\n distress secondary to CHF: , (MICU stay), \n (MICU stay/BiPAP). On discussions with the patient and his family the\n decision was made to change his code status to DNR/ but ok to intubate\n (for short time).\n S/O:\n Lasix gtt was d/c\nd at 1200. Started back on torsemide at 1200. . Dose\n increased to 30 mg. UO 80 cc x 4hrs. SBP 90\ns to low 100\ns. HR 70\n V-paced. No VEA noted. Fld balance even since MN\n BS 172.On SS insulin. Holding glipizide. On heart healthy diet,\n 1000cc FR.\n Abd soft, distended\n Afeb\n" }, { "category": "Nursing", "chartdate": "2157-10-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 420541, "text": " yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who\n presents from his with increased shortness of breath.\n His torsemide dose had recently been increased from 10mg to 20mg daily\n over the weekend given weight gain, poor urinary output and rales on\n exam per visiting nursing. On this dose was increased to 40mg\n daily, however, without substantial benefit and pt was referred to ED\n today for respiratory distress. According to his son, prior to this\n time he had been doing well on the torsemide, however still had very\n poor exercise tolerance and even the smallest task (such as weighing\n himself) causes him to become dyspnea.\n .\n He has had multiple recents admissions for hypoxia and respiratory\n distress secondary to CHF: , (MICU stay), \n (MICU stay/BiPAP). On discussions with the patient and his family the\n decision was made to change his code status to DNR/ but ok to intubate\n (for short time).\n S/O: Pt reports breathing at or near baseline\n Lasix gtt was d/c\nd at 1200. Started back on torsemide at 1200. . Dose\n increased to 30 mg. UO 80 cc x 4hrs. SBP 90\ns to low 100\ns. HR 70\n V-paced. No VEA noted. Fld balance even since MN\n BS diminished at bases, crackles on R, clear L. Audible wheezes at X\n FS 172.On SS insulin. Holding glipizide. On heart healthy diet,\n 1000cc FR.\n Abd soft, distended\n \n Sons & phoned & were updated on pt\ns condition & POC. They\n have indicated they are both pt\ns HCP\n Pt DNR but would be intubated if necessary for short period\n A/P: Resp status at or near baseline.\n UO has dropped off past 4 hrs. If no improvement in next one to\n two hrs, give IV lasix\n Son reports pt has 24 hr assistance (aides) at \n Senior Center and requests 24 hr notice prior to pt being discharged so\n he can arrange for 24 hr care for pt .\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 72.6 kg\n Daily weight:\n Allergies/Reactions:\n Sulfonamides\n Unknown;\n A.C.E Inhibitors\n Cough;\n Protonix (Oral) (Pantoprazole Sodium)\n Rash;\n Precautions:\n PMH:\n CV-PMH: CHF\n Additional history: DM type II, nod pulm HTN, BPH, S/p TURP, CKD\n (baseline Cr 2-2.2), gout, partial hip replacement last yr after fall,\n macular degeneration R eye\n Surgery / Procedure and date: CABG in 79\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:47\n Temperature:\n 95\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Face tent\n O2 saturation:\n 98% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 891 mL\n 24h total out:\n 875 mL\n Pacer Data\n Permanent pacemaker rate:\n 70 /min\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:10 AM\n Potassium:\n 4.0 mEq/L\n 05:10 AM\n Chloride:\n 101 mEq/L\n 05:10 AM\n CO2:\n 25 mEq/L\n 05:10 AM\n BUN:\n 100 mg/dL\n 05:10 AM\n Creatinine:\n 3.3 mg/dL\n 05:10 AM\n Glucose:\n 51 mg/dL\n 05:10 AM\n Hematocrit:\n 24.8 %\n 05:10 AM\n Finger Stick Glucose:\n 80\n 07:00 AM\n Valuables / Signature\n Patient valuables: hearing aide R ear. Dentures upper & lower\n Other valuables:\n Clothes: Sent home with: Bag of clothing & suitcase with clothing\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: silver colored wrist watch\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2157-10-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 420396, "text": "Chief Complaint: Respiratory distress, hypoxia\n HPI:\n yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who\n presents from his with increased shortness of breath.\n His torsemide dose had recently been increased from 10mg to 20mg daily\n over the weekend given weight gain, poor urinary output and rales on\n exam per visiting nursing. On this dose was increased to 40mg\n daily, however, without substantial benefit and pt was referred to ED\n today for respiratory distress. According to his son, prior to this\n time he had been doing well on the torsemide, however still had very\n poor exercise tolerance and even the smallest task (such as weighing\n himself) causes him to become dyspnea.\n .\n He has had multiple recents admissions for hypoxia and respiratory\n distress secondary to CHF: , (MICU stay), \n (MICU stay/BiPAP). On discussions with the patient and his family the\n decision was made to change his code status to DNR/ but ok to intubate\n (for short time).\n .\n In ED, VS were T 97.1 HR 70 (paces ) 115/59, RR 32, O2 sat low 80s on\n 100% NRB. He was acutely SOB with increased work of breathing and\n placed on BiPAP 10/5 (FiO2 100% - 40%). He had some symptomatic\n improvement with this. His CXR was consistent with pulmonary edema and\n given concern for possible underlying pneumonia, he was treated with\n CTX and azithromycin in addition to 100mg IV Lasix.\n .\n ROS: as above. Negative for fever, chills. +weight gain. +R hand\n weakness (unchanged). + LE edema. No abdominal pain, nausea, vomiting,\n diarrhea or constipation\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Sulfonamides\n Unknown;\n A.C.E Inhibitors\n Cough;\n Protonix (Oral) (Pantoprazole Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Aspirin 81 mg po daily\n Senna 8.6 mg po bid\n Tamsulosin 0.4 mg po qhs\n Glipizide 10 mg po daily\n Torsemide 10 mg po daily\n Carvedilol 6.25 mg po bid\n Albuterol INH prn\n Home oxygen at 2L/min continuous\n Past medical history:\n Family history:\n Social History:\n Type II diabetes mellitus\n CAD s/p CABG in \n Single chamber PPM for CHB\n EF 45%, 1+ MR/ 3+TR ()\n Moderate pulmonary HTN\n Left temporal lobe infarct (recent admit - )\n BPH s/p TURP\n CKD - recent baseline creatinine ranges from 2.8-3.4\n Gout\n Partial Hip replacement last year after fall\n Macular Degeneration on R eye\n B/L vision loss\n Hearing loss\n Mother with CAD in her 50s died from myocardial infarction\n Occupation: retired\n Drugs: none\n Tobacco: past\n Alcohol: rare\n Other: Used to work in a confectionary store in . Now lives\n in facility with his wife. two sons, one in ,\n both involved in care. 30 pack year smoking history of cigars and\n pipes. Rarely drinks EtOH. Denies illicits\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.2\nC (95.3\n Tcurrent: 35.2\nC (95.3\n HR: 70 (70 - 70) bpm\n BP: 103/57(68) {90/47(62) - 104/59(68)} mmHg\n RR: 23 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 285 mL\n Urine:\n 205 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -285 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: L pupil surgical\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\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 1/3 up bases b/l, No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: 1+, Left: Trace, No(t) Clubbing\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 103\n 199\n 3.3\n 99\n 23\n 99\n 5.1\n 135\n 27.7\n 5.3\n [image002.jpg]\n Other labs: Differential-Neuts:80.6, Lymph:10, Mono:7.1, Eos:2\n Fluid analysis / Other labs: U/A: neg LE, neg nitr, neg ket, neg\n glucose\n Imaging: CXR : PRELIM: Heart enlarged, diffuse airspace\n intersitial opacities suggestive of volume overload/CHF. Mod. R pleural\n effusion and small L pleural effusion increased in size from .\n .\n ECHO :\n The left atrium is mildly dilated. The right atrium is moderately\n dilated. No atrial septal defect is seen by 2D or color Doppler. The\n estimated right atrial pressure is 10-20mmHg. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal.\n There is mild global left ventricular hypokinesis (LVEF = 45 %). No\n masses or thrombi are seen in the left ventricle. There is no\n ventricular septal defect. The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. There is abnormal\n septal motion/position. The ascending aorta is mildly dilated. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Mild (1+) aortic regurgitation is seen. The mitral valve\n leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\n The tricuspid valve leaflets are mildly thickened. Moderate to severe\n [3+] tricuspid regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n .\n CT Head :\n 1. Probable acute infarction in the left temporal lobe. MRI is\n recommended for further evaluation. If the patient cannot tolerate MRI,\n follow-up CT is suggested.\n 2. Age-related cerebral atrophy. Chronic small vessel ischemic changes.\n 3. Left mastoid tip air cell opacification.\n ECG: V-paced at 70 bpm\n Assessment and Plan\n Assessment: yo M w/ CHF, CAD s/p CABG, CKD, DM2 who presents with\n respiratory distress likely secondary to CHF flare and pulmonary edema\n initiated on BiPAP in the ED.\n .\n Plan:\n # SOB/Dyspnea: Most likely is CHF exacerbation based on history,\n multiple recent admissions for this, and pulmonary edema on CXR. No\n clinical signs or symptoms of infection, except possibly for hypoxia\n which can be explained by volume overload. No fever or chills and no\n consolidation on CXR. Despite recent changes in his home medication\n (addition of torsemide, carvedilol), cont. to have inadequate diuresis.\n Started on BiPAP in ED with improvement in respiratory status. Rec'd\n 100mg IV Lasix with good response. Upon arrival to ICU, respiratory\n status improved OFF of BiPAP - satting well on facemask.\n - Start Lasix drip, titrate to goal negative -1L\n - Consider adding Diuril to enhance diuresis if needed\n - Cont. carvedilol at current dose\n - Cycle CEs, monitor on telemetry\n - Monitor K and replete prn\n .\n # CAD s/p remote CABG: Will cycle CEs as above. Pt denies chest pain.\n - Cont. Aspirin, B-blocker\n - Monitor on telemetry\n .\n # Stage 4 CKD: Creatinine range 2.8-3.4 on recent admissions which\n unfortunately appears to be a new baseline, most likely the result of\n severe heart failure and chronic diuretic therapy\n - renally dose medications\n - trend creatinine as diuresing\n - monitor electrolytes\n .\n # Anemia: Baseline CRIT approx 24. Iron studies done recently and no\n acute abnormalities except for mild iron deficiency. Endoscopy deferred\n given pt's age. also be related to chronic renal failure. Stable\n today at 27, will not transfuse given already profound volume overload.\n .\n # Rhythm - pt s/p PPM for CHB, V-paced at rate of 70\n .\n # BPH: Cont. Flomax\n .\n # Diabetes mellitus type II: Hold glipizide, treat with humalog ISS\n .\n # FEN: Diabetic/low sodium diet, fluid restrict to 1L/d. Replete lytes\n prn\n .\n # PPx: heparin sc, bowel regimen, no PPI - pt has Protonix allergy\n .\n # Access: PIV\n .\n # Comm: son , son both are HCPs\n .\n # Code: DNR/ ok to intubate for short trial\n .\n # Dispo: ICU care\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:33 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Radiology", "chartdate": "2157-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1041156, "text": " 6:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change in pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with CHF\n REASON FOR THIS EXAMINATION:\n assess interval change in pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged moderate\n pulmonary edema accompanied by bilateral pleural effusions. Also unchanged is\n the amount of interstitial fluid accumulation and the size of the cardiac\n silhouette. No evidence of newly appeared parenchymal opacities. Unchanged\n right-sided pacemaker.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1041066, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for sob\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with sob\n REASON FOR THIS EXAMINATION:\n eval for sob\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old male with shortness of breath, evaluate for shortness of\n breath.\n\n COMPARISON: .\n\n AP PORTABLE UPRIGHT CHEST, ONE VIEW: A pacer overlies the right chest wall,\n with a lead terminating in the right ventricle. Heart is enlarged in size,\n with an unfolded aorta. There are diffuse airspace and interstitial opacities\n bilaterally, suggestive of pulmonary edema. Additionally, there is a moderate\n right pleural effusion and a small left pleural effusion, increased in size\n from .\n\n IMPRESSION: Moderate CHF, with pulmonary edema and bilateral pleural\n effusions, worse from .\n\n" }, { "category": "Radiology", "chartdate": "2157-10-13 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1041547, "text": " 9:53 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: R/O DVT RT ARM > LT ARM RT ARM SWELLING\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with R > L swelling of arm, r/o dvt\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:06 AM\n No evidence of DVT in the right upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swelling of the right arm greater than the left.\n\n There are no prior studies for comparison.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the\n right internal jugular, subclavian, axillary, brachial, basilic and cephalic\n veins were performed. Normal flow, augmentation, compressibility were\n appropriate and waveforms were demonstrated. No intraluminal thrombus is\n identified.\n\n IMPRESSION: No evidence of DVT in the right upper extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-10-13 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1041548, "text": ", K. MED 11R 9:53 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: R/O DVT RT ARM > LT ARM RT ARM SWELLING\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with R > L swelling of arm, r/o dvt\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the right upper extremity.\n\n\n" }, { "category": "ECG", "chartdate": "2157-10-10 00:00:00.000", "description": "Report", "row_id": 156591, "text": "Baseline artifact. Ventricular paced rhythm. Since the previous tracing\nof no significant change.\n\n" }, { "category": "Nursing", "chartdate": "2157-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420421, "text": "HPI:\n yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who\n presents from his with increased shortness of breath.\n His torsemide dose had recently been increased from 10mg to 20mg daily\n over the weekend given weight gain, poor urinary output and rales on\n exam per visiting nursing. On this dose was increased to 40mg\n daily, however, without substantial benefit and pt was referred to ED\n today for respiratory distress. According to his son, prior to this\n time he had been doing well on the torsemide, however still had very\n poor exercise tolerance and even the smallest task (such as weighing\n himself) causes him to become dyspnea.\n .\n He has had multiple recents admissions for hypoxia and respiratory\n distress secondary to CHF: , (MICU stay), \n (MICU stay/BiPAP). On discussions with the patient and his family the\n decision was made to change his code status to DNR/ but ok to intubate\n (for short time).\n .\n Pulmonary edema\n Assessment:\n Lungs with crackles in the RLL otherwise clear. Sao2 has ranged from\n 97-100%. No cough noted. RR 15-21.\n Action:\n Pt was on 40% shovel mask and was changed to 2L N/C. pt is receiving\n his hs dose of torsemide and is on a lasix gtt at 6mg hr.\n Response:\n U/O is >30cc hr. pt has had no sob or resp distress since adm to MICU.\n Plan:\n Cont to monitor lytes and replenish as needed. Cont to monitor u/o and\n keep >30cc hr. goal was to have pt 1L neg by am but u/o is not on track\n to meet this.\n" }, { "category": "Physician ", "chartdate": "2157-10-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 420501, "text": "Chief Complaint: resp failure, diastolic CHF\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 Did well overnight on lasix drip, never required BiPAP. 400cc neg\n overnight.\n 24 Hour Events:\n No complaints this morning. Pt feels well, feels his breathing is at\n baseline. On home level of supplemental O2 (2L NC).\n History obtained from Medical records\n Allergies:\n Sulfonamides\n Unknown;\n A.C.E Inhibitors\n Cough;\n Protonix (Oral) (Pantoprazole Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 6 mg/hour\n Other ICU medications:\n Other medications:\n ISS, carvedilol 6.25, asa, colace\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: Pt feels well, denies any pain, respiratory\n distress. Says he feels as well as he does at home. No GI distress,\n lightheadedness, dysuria.\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 (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 70 (67 - 70) bpm\n BP: 108/59(73) {89/17(42) - 112/66(98)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 254 mL\n 58 mL\n PO:\n 240 mL\n TF:\n IVF:\n 14 mL\n 58 mL\n Blood products:\n Total out:\n 325 mL\n 605 mL\n Urine:\n 245 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n -71 mL\n -547 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Not significantly changed since last night. Appears comfortable. No\n respiratory distress. Laying in bed, sat up easily with some\n assistance. Crackles at bases. Good air movement. Distant heart sounds.\n Abd soft, NTND. compression stockings on LEs with improvement in LE\n edema.\n Labs / Radiology\n 8.4 g/dL\n 102 K/uL\n 51 mg/dL\n 3.3 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 100 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 08:48 PM\n 05:10 AM\n WBC\n 5.8\n Hct\n 24.8\n Plt\n 102\n Cr\n 3.3\n TropT\n 0.01\n Glucose\n 51\n Other labs: PT / PTT / INR:18.3/39.9/1.7, CK / CKMB /\n Troponin-T:99/4/0.01, Mg++:2.6 mg/dL, PO4:5.0 mg/dL\n Imaging: CXR not significantly changed since last night\n Assessment and Plan\n Predominantly diastolic CHF with 4 admissions for resp\n failure/hypoxemia in less than 2 months.\n CHF: Improved hypoxemia with mild diuresis.\n Change to PO dose of torsemide from lasix gtt\n Continue asa, beta blocker\n Meet with pt\ns son, who is HCP to discuss severity of chronic illness\n and code status (he is DNR but not DNI).\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:33 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Code status: DNR (do not resuscitate)\n Disposition :Transfer to medical floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2157-10-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 420504, "text": "Chief Complaint: Respiratory Distress\n 24 Hour Events:\n - pt on lasix drip (6mg/hr) --> pt negative ~400cc\n Patient unable to provide history: pt with difficulty hearing\n Allergies:\n Sulfonamides\n Unknown;\n A.C.E Inhibitors\n Cough;\n Protonix (Oral) (Pantoprazole Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 6 mg/hour\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 Respiratory: No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:32 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: 36.4\nC (97.5\n HR: 70 (67 - 70) bpm\n BP: 106/62(98) {89/17(42) - 112/66(98)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 254 mL\n 38 mL\n PO:\n 240 mL\n TF:\n IVF:\n 14 mL\n 38 mL\n Blood products:\n Total out:\n 325 mL\n 375 mL\n Urine:\n 245 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -71 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Crackles :\n b/l 2/3 up the lung fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed, pt with hearing loss\n Labs / Radiology\n 8.4 g/dL\n 23 mEq/L\n 4.3 mEq/L\n 100 mEq/L\n 136 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 08:48 PM\n 05:10 AM\n WBC\n 5.9\n 5.8\n Hct\n 27.7\n 24.8\n TropT\n 0.01\n Other labs: PT / PTT / INR:18.3/39.9/1.7, CK / CKMB /\n Troponin-T:99/4/0.01, Mg++:2.6 mg/dL\n Assessment and Plan\n Assessment: yo M w/ CHF, CAD s/p CABG, CKD, DM2 who presents with\n respiratory distress likely secondary to CHF flare and pulmonary edema\n initiated on BiPAP in the ED.\n .\n Plan:\n # SOB/Dyspnea: Most likely is CHF exacerbation based on history,\n multiple recent admissions, and pulmonary edema on CXR. No clinical\n signs or symptoms of infection. No fever, leukocytosis and no\n consolidation on CXR. Despite recent changes in his home medication\n (addition of torsemide, carvedilol), cont. to have inadequate\n diuresis. Rec'd 100mg IV Lasix and started on lasix gtt. Pt satting\n well on nasal cannula. Pt is negative ~400cc since admission.\n - Will start torsemide 30mg \n - will d/c lasix drip\n - Cont. carvedilol at current dose\n - t/c increasing diuretics if not negative -1L today\n - check PM lytes and replete prn\n .\n # CAD s/p remote CABG: Will cycle CEs as above. Pt denies chest pain.\n - Cont. Aspirin, B-blocker\n - Monitor on telemetry\n .\n # Stage 4 CKD: Creatinine range 2.8-3.4 on recent admissions which\n unfortunately appears to be a new baseline, most likely the result of\n severe heart failure and chronic diuretic therapy\n - renally dose medications\n - trend creatinine as diuresing\n - monitor electrolytes\n .\n # Anemia: recent Baseline CRIT approx 24. Hct is 24.4 today. Iron\n studies done recently and no acute abnormalities except for mild iron\n deficiency. Endoscopy deferred given pt's age. also be related to\n chronic renal fail, will not transfuse given already profound volume\n overload.\n .\n # Rhythm - pt s/p PPM for CHB, V-paced at rate of 70\n .\n # BPH: Cont. Flomax\n .\n # Diabetes mellitus type II: Hold glipizide, treat with humalog ISS\n .\n # FEN: Diabetic/low sodium diet, fluid restrict to 1L/d. Replete lytes\n prn\n .\n # PPx: heparin sc, bowel regimen, no PPI - pt has Protonix allergy\n .\n # Access: PIV\n .\n # Comm: son , son both are HCPs\n .\n # Code: DNR/ ok to intubate for short trial\n .\n # Dispo: If hemodynamically stable can transfer to floor today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:33 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2157-10-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 420467, "text": "Chief Complaint: Respiratory Distress\n 24 Hour Events:\n - pt on lasix drip (6mg/hr) --> pt negative ~400cc\n Patient unable to provide history: pt with difficulty hearing\n Allergies:\n Sulfonamides\n Unknown;\n A.C.E Inhibitors\n Cough;\n Protonix (Oral) (Pantoprazole Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 6 mg/hour\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 Respiratory: No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:32 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: 36.4\nC (97.5\n HR: 70 (67 - 70) bpm\n BP: 106/62(98) {89/17(42) - 112/66(98)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 254 mL\n 38 mL\n PO:\n 240 mL\n TF:\n IVF:\n 14 mL\n 38 mL\n Blood products:\n Total out:\n 325 mL\n 375 mL\n Urine:\n 245 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -71 mL\n -337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Crackles :\n b/l 2/3 up the lung fields)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed, pt with hearing loss\n Labs / Radiology\n 8.4 g/dL\n 23 mEq/L\n 4.3 mEq/L\n 100 mEq/L\n 136 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 08:48 PM\n 05:10 AM\n WBC\n 5.9\n 5.8\n Hct\n 27.7\n 24.8\n TropT\n 0.01\n Other labs: PT / PTT / INR:18.3/39.9/1.7, CK / CKMB /\n Troponin-T:99/4/0.01, Mg++:2.6 mg/dL\n Assessment and Plan\n Assessment: yo M w/ CHF, CAD s/p CABG, CKD, DM2 who presents with\n respiratory distress likely secondary to CHF flare and pulmonary edema\n initiated on BiPAP in the ED.\n .\n Plan:\n # SOB/Dyspnea: Most likely is CHF exacerbation based on history,\n multiple recent admissions, and pulmonary edema on CXR. No clinical\n signs or symptoms of infection. No fever, leukocytosis and no\n consolidation on CXR. Despite recent changes in his home medication\n (addition of torsemide, carvedilol), cont. to have inadequate\n diuresis. Rec'd 100mg IV Lasix and started on lasix gtt. Pt satting\n well on nasal cannula. Pt is negative ~400cc since admission.\n - Cont Lasix drip, titrate to goal negative -1L\n - Consider adding Diuril to enhance diuresis if needed\n - Cont. carvedilol at current dose\n - CE negative x2, monitor on telemetry\n - Monitor K and replete prn\n .\n # CAD s/p remote CABG: Will cycle CEs as above. Pt denies chest pain.\n - Cont. Aspirin, B-blocker\n - Monitor on telemetry\n .\n # Stage 4 CKD: Creatinine range 2.8-3.4 on recent admissions which\n unfortunately appears to be a new baseline, most likely the result of\n severe heart failure and chronic diuretic therapy\n - renally dose medications\n - trend creatinine as diuresing\n - monitor electrolytes\n .\n # Anemia: recent Baseline CRIT approx 24. Hct is 24.4 today. Iron\n studies done recently and no acute abnormalities except for mild iron\n deficiency. Endoscopy deferred given pt's age. also be related to\n chronic renal fail, will not transfuse given already profound volume\n overload.\n .\n # Rhythm - pt s/p PPM for CHB, V-paced at rate of 70\n .\n # BPH: Cont. Flomax\n .\n # Diabetes mellitus type II: Hold glipizide, treat with humalog ISS\n .\n # FEN: Diabetic/low sodium diet, fluid restrict to 1L/d. Replete lytes\n prn\n .\n # PPx: heparin sc, bowel regimen, no PPI - pt has Protonix allergy\n .\n # Access: PIV\n .\n # Comm: son , son both are HCPs\n .\n # Code: DNR/ ok to intubate for short trial\n .\n # Dispo: If hemodynamically stable can transfer to floor today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:33 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2157-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420463, "text": "HPI:\n yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who\n presents from his with increased shortness of breath.\n His torsemide dose had recently been increased from 10mg to 20mg daily\n over the weekend given weight gain, poor urinary output and rales on\n exam per visiting nursing. On this dose was increased to 40mg\n daily, however, without substantial benefit and pt was referred to ED\n today for respiratory distress. According to his son, prior to this\n time he had been doing well on the torsemide, however still had very\n poor exercise tolerance and even the smallest task (such as weighing\n himself) causes him to become dyspnea.\n .\n He has had multiple recents admissions for hypoxia and respiratory\n distress secondary to CHF: , (MICU stay), \n (MICU stay/BiPAP). On discussions with the patient and his family the\n decision was made to change his code status to DNR/ but ok to intubate\n (for short time).\n .\n Pulmonary edema\n Assessment:\n Lungs with crackles in the RLL otherwise clear. Sao2 has ranged from\n 97-100%. No cough noted. RR 15-21.\n Action:\n Pt was on 40% shovel mask and was changed to 2L N/C. pt is receiving\n his hs dose of torsemide and is on a lasix gtt at 6mg hr.\n Response:\n U/O is >30cc hr. pt has had no sob or resp distress since adm to MICU.\n Plan:\n Cont to monitor lytes and replenish as needed. Cont to monitor u/o and\n keep >30cc hr. goal was to have pt 1L neg by am but u/o is not on track\n to meet this.\n Pt has remained A&O throughout the shift. Very HOH and has a hearing\n aide in the right ear.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 1517989, "text": "NURSING ADMIT NOTE\nTHIS IS A 47 YR OLD MALE ADM FROM AN OSH TO THE MICU ON THE CCU SERVICE. HE AWOKE AT 0400 WITH PALPITATIONS AND CHEST TIGHTNESS, AND HAD HIM TO THE HOSP AT 10 AM..HE WAS STARTED ON A HEPARIN AND INTEGRELIN INFUSION. INITIALLY, HIS PAIN WAS DESCRIBED AS A ..HE WAS GIVEN SL NTG, IV LOPRESSOR AND MS04.HE RULED IN THERE BY CK'S AND TROPONIN. HIS EKG SHOWED .5- ^^ INF. HE WAS TRANSFERED VIA GROUND EMS AT 8 PM ON WITH CHEST \" CONGESTION \" DESRIBED AS A . HE WAS STARTED ON IV NTG AND INTEGRELIN ..GIVEN A TOTAL OF 10 MG OF IV LOPRESSOR, 3 SL NTG AND ONE MG OF IV ATIVAN. A STAT BEDSIDE ECHO REVEALED A SMALL AREA OF HYPOKINESIS INF.WITH AN EF > 45%.\n\nPMHX OF WPW\n 1 PACK SMOKER\n ADMITS TO A SIGNIFICANT ETOH CONSUMPTION OF ONE TO ONE AND A HALF PINTS OF VODKA ..HAS BEEN UNABLE TO STOP ETOH WITHOUT SIGNIFICANT NIGHT SWEATS, TREMORS AND NIGHTMARES\n UPON ARRIVAL TO THE MICU ..HE HAS BEEN HEMODYN STABLE\n\nCV HR MID 80'S-90'S..THE CCU SERVICE HAS BEEN INCREASING PO DOSE OF LOPRESSOR ..IV NTG AT 1.2 MCGS/KG/MIN..HEPARIN IS AT 950 U/HR WITH A PTT OF 57..INTEGRELIN IS A 2 MCGS/KG/MIN..DENIES CHEST PAIN AT THIS TIME .\nRESP LUNGS CLEAR ..02 SAT IS 96% ON ROOM AIR\nGI DENIES NAUSEA\nGU VOIDING IN URINAL\nDISTAL PULSES 3+/3+\nCIWA SCALE PER CAREVIEW FLOWSHEET ...REPORTS INSOMNIA AND MOD AMOUNT OF ANXIETY ..AND A HEADACHE WHICH BEGAN AT 0600..GIVEN TYLENOL...\nA CHEST PAIN ..RULING IN BY ENZYMES\nP CATH ON MONDAY\n" }, { "category": "Nursing/other", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 1517990, "text": "FULL CODE NKDA Universal Precautions\n\n\nNeuro: AAOx3. OOB to commode/use the urinal w/ no difficulties. On CIWA protocol for ETOH/DTs. Pt has not exhibited any s/sx DTs, yet. Med w/ Ativan 1mg TID prophylactically.\n\nResp: 95-97% on room air. Pt will not keep n/p on. Lungs clear, no cough.\n\nCardiac: HR=80-90s, NSR, no ectopy. On lopressor 50mg TID w/ no effect on HR. Remains on heparin gtt at 950 units/hr w/ last PTT-50. NTG gtt at 1.12 mcg/kg/min; pt has been pain-free since midnight. Integrellin gtt complete. Pt has had many nosebleeds over the course of the day, MDs aware and last PTT=50. BP=100-120/50s. +pedal pulses, extrems warm, no edema. Cardiac cath scheduled for tomorrow .\n\nGI/GU: Abd round, soft, +BS, BMx2 - soft/liquid, heme neg. Taking cardiac diet well. Voiding clear yellow urine\n\nPain: No CP since midnight. Remains on NTG gtt at 1.12 mcg/kg/min. Pt had a headache this am which resolved w/ tylenol. C/o chest \"congestion\", like a cold.\n\nSkin: intact.\n\nAccess: PIVx3.\n\nLabs: Magnesium and Potassium repleted this am and levels WNL. FS=336 - covered by RISS. MDs did not want to put pt back on oral med.\n\nSocial: Wife and son in to visit.\n\nPlan: Tx to 6 when bed available. Monitor cardiac/neuro/resp status. Maintain heparin and NTG gtts, PTT per heparin protocol. Maintain CIWA protocol - med w/ Ativan as ordered. Cardiac cath to be done tomorrow .\n" }, { "category": "Echo", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 61614, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain.\nBP (mm Hg): 140/80\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 05:52\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\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction.\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: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is mild regional\nleft ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include basal to mid inferior and inferolateral\nhypokinesis/akinesis. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 114042, "text": "Sinus rhythm. Short P-R interval and QRS configuration with delta waves and\nST-T wave changes - pattern is consistent with ventricular pre-excitation -\n-Parkinson-White syndrome pattern. Clinical correlation is suggested.\nSince the previous tracing of further QRS and ST-T wave changes are\npresent.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2165-11-07 00:00:00.000", "description": "Report", "row_id": 1352408, "text": "Nursing progress note:\n\nNeuro: Pt. remains alert,oriented,cooperative,and pleasant. He has no c/o pain and MAE.\n\nCV: HR 95-116, a-fib with occ PVCs,NBP 101-156/60-80. Pt. still has two PIVs in L arm which are both patent and WNL but will be out of date so new 18g placed in L AC. Hct dropped from 34 to 30.8, team notified,no interventions ordered. K is 4.3 and Mag is 2.0\n\nResp: RR 15-26,02 sats>95% oon room air. No signs of resp distress although pt. states he sleeps in a recliner at home due to \"apnea\". Pt. now sitting in chair and is much more comfortable.\n\nGI/GU: UO >30cc/hour voiding in urinal, 200cc dark brown stool via mushroom cath and one large stool when mushroom cath bag became detached when pt. turned. Pt.is going to the today for EGD and EUS (esophageal ultrasound?) and has been NPO since MN for procedure.Abd soft, non-tender with BSX4.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-11-06 00:00:00.000", "description": "Report", "row_id": 1352406, "text": "Nursing progress note:\n\nPt.is a 67 yo man who had a ventral hernia repair on at , was placed on Heparin due to his chronic a-fib and subsequently developed melanotic stools and hemoptysis. A PE was ruled out but the chest CT showed an intraluminal mass to the distal esophagus. His Hct dropped from 37 to 33 on . An EGD showed a large clot at the GE junction with a poss. intramural mass. Pt. was transferred to for further evaluation and endoscopic ultrasound.\n\nNeuro:Pt.is awake,alert,oriented,pleasant and cooperative,MAE and has no c/o pain.\n\nCV:HR 110-120s, a-fib with occasional PVCs. Pt. has chronic a-fib and receives Metoprolol routinely which kept HR below 120s. NBP 140-160s/ 60-80s.Electrolytes came back as K 3.2 and Mag 1.9. Team notified and will enter orders for repletion. Hct also dropped from 31.3 to 29.3, team aware.Pt. has 2 PIVs in R arm, both patent and WNL.\n\nResp: RR 19-25, 02sats>95%, LSCTA, no resp issues.\n\nGI: Pt. had frequent small melanotic stools, rectal bag applied.Abd. is soft,non-tender with BSX4. Pt. is NPO for EGD in am.\n\nGU: Pt. voids in urinal with output WNL.\n\nSkin: Pt. has stapled incision to lower abdomen and JP drain in RLQ draining serosanguinous fluid. Both sites healing well.\n\nSocial: Family members visited pt. in evening.\n\nPlan: EGD,replete electrolytes, monitor Hct-next due at 1200.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-11-06 00:00:00.000", "description": "Report", "row_id": 1352407, "text": "Nursing Progress Note 0700-1900\nEvents: EGD not done. To be transferred to for EGD/US tomorrow. Hct stable. Small amt melena cont.\n\nReview of systems:\n\nNeuro: AAO X 3, denies pain or nausea. MAEE in bed, turning self STS without difficulty.\n\nResp: Sating 98-100% on 2l NC with RR 17-25 and regular. Lung snds clear.\n\nCV: HR 103-135AFib with occas PVC's. BP 134/59-166/86. Lopressor increased to 20mg IV Q4hrs, Hydralazine increased to 40mg IV Q6hrs. Hct @ 1500 34.7 (29.3). No transfusions. Small amt melena continues. K+ repleted in am.\n\nGI: No N/V, denies discomfort. Pt has remained NPO in anticipation in EGD, which has been deferred until tomorrow. Pt may have clear liqs until MN, then NPO for procedure tomorrow. Rec'ing D5.45NS @ 100ml/hr X 2liters. Rectal bag leaked mod amt melena, replaced by mushroom cath which has drained small amt liquid melena.\n\nGU: Voiding yellow/clear in amts per carevue. 24hr fluid balance @ 1800 -452ml.\n\nID: Tmax 99.2.\n\nSkin: Abdominal staple line D&I, open to air. J-P drain with 40ml serosang fluid out this shift.\n\nAccess: Periph IV in RLL ? leaking.\n\nSocial: Family members @ bedside, supportive.\n\nPlan: Clear liqs, then NPO after MN. Transfer to for EGD/US. Re-check Hct, K+ this pm. ? new IV access.\n" }, { "category": "Radiology", "chartdate": "2165-11-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 892403, "text": " 9:44 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval for infiltrate and effusion.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ? pleural effusion and decreased BS on R.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate and effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased breath sounds on the right.\n\n FINDINGS: Moderate cardiomegaly and severe left atrial enlargement are\n unchanged compared to . The lungs are clear with no parenchymal\n consolidation, pulmonary nodules, or pneumothorax. An effusion is seen on the\n lateral radiograph.\n\n IMPRESSION: Moderate cardiomegaly and severe left atrial enlargement. No\n evidence of CHF or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2165-11-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 892522, "text": " 3:17 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval for pulm edema.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with SOB and hx of CHF.\n REASON FOR THIS EXAMINATION:\n Eval for pulm edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS\n\n INDICATION: 67-year-old man with shortness of breath and congestive heart\n failure.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with the previous study of yesterday.\n\n There is continued marked cardiomegaly and small bilateral effusion, which are\n not changed since the previous radiograph. Again, note is made of marked\n tortuosity of the thoracic aorta with calcification.\n\n There is no evidence of congestive heart failure.\n\n IMPRESSION: Continued marked cardiomegaly and small bilateral effusions. No\n evidence of congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892135, "text": " 7:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: admission CXR, evaluate for free air\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with likely esophageal mass\n REASON FOR THIS EXAMINATION:\n admission CXR, evaluate for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with likely esophageal mass.\n\n CHEST, UPRIGHT AP PORTABLE: There are no prior studies available for\n comparison. There is moderately severe cardiomegaly. The lungs are clear.\n There is no evidence of pneumothorax or pleural effusion, although the left\n costophrenic angle is not included. No evidence of free air is seen under the\n hemidiaphragms.\n\n IMPRESSION: Cardiomegaly, but no evidence of acute cardiopulmonary process or\n free air.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2107-07-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688571, "text": "Chief Complaint: L subclavian clot\n 24 Hour Events:\n SHEATH - START 07:05 PM\n - No overnight events\n - Knee pain stable\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Cefazolin - 02:03 AM\n Infusions:\n Alteplase (TPA) - 0.25 mg/hour\n Heparin Sodium - 300 units/hour\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 07:37 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 (97.5\n HR: 78 (64 - 89) bpm\n BP: 135/79(92) {124/66(80) - 155/86(102)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 461 mL\n 972 mL\n PO:\n TF:\n IVF:\n 461 mL\n 972 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, L knee swelling, no warmth or redness; LUE\n swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): AAO X3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 183 K/uL\n 9.0 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 109 mEq/L\n 142 mEq/L\n 26.2 %\n 5.4 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n WBC\n 5.4\n Hct\n 27.0\n 26.2\n Plt\n 183\n Cr\n 1.2\n Glucose\n 102\n Other labs: PT / PTT / INR:15.8/38.1/1.4, ALT / AST:38/75, Alk Phos / T\n Bili:64/0.3, Fibrinogen:131 mg/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram today\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures continue to be negative, sotp antibiotics (Vanc needs\n approval)\n c. Steroids not started yesterday. Give Prednisone 30mg po today\n then 20mg qday x1 then 10mg po qday x1 then stop\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.2\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: replete phose\n ICU Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2107-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688799, "text": "Chief Complaint:\n 24 Hour Events:\n SHEATH - STOP 03:00 PM\n -s/p LUE thrombectomy by IR. Doing well post-procedure. Abx d/c'd.\n Restarted heparin drip at weight based dosing, plan to start lovenox in\n AM, which he will be on for the next 3 months for anticoagulation.\n Resumed diet and activity. Called out, waiting on bed.\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Cefazolin - 08:50 AM\n Vancomycin - 10:00 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other medications:\n Other medications:\n 1000 mL NS 4. Colchicine 5. Heparin 6. Hydrocodone-Acetaminophen 7.\n Lisinopril 8. Loperamide\n 9. Magnesium Sulfate 10. Ondansetron ODT 11. Pantoprazole 12.\n Pneumococcal Vac Polyvalent 13. Potassium Chloride\n 14. Potassium Chloride 15. Prochlorperazine 16. Sodium Chloride 0.9%\n Flush\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: +pain at catheter site in left arm but decreased\n left hand erythema; decreased left knee pain; no SOB, no CP\n Flowsheet Data as of 07:28 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: 36.7\nC (98\n HR: 68 (66 - 103) bpm\n BP: 143/84(97) {107/58(69) - 157/87(104)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,846 mL\n 1,059 mL\n PO:\n 640 mL\n 240 mL\n TF:\n IVF:\n 3,206 mL\n 819 mL\n Blood products:\n Total out:\n 1,900 mL\n 1,400 mL\n Urine:\n 1,900 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n -341 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Gen: NAD\n HEENT: +edema\n Labs / Radiology\n 174 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.0 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 25.8 %\n 3.7 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n 01:16 AM\n WBC\n 5.4\n 3.7\n Hct\n 27.0\n 26.2\n 25.8\n Plt\n 183\n 174\n Cr\n 1.2\n 1.1\n Glucose\n 102\n 122\n Other labs: PT / PTT / INR:16.8/137.7/1.5, ALT / AST:31/68, Alk Phos /\n T Bili:62/0.3, Differential-Neuts:55.2 %, Lymph:30.4 %, Mono:10.3 %,\n Eos:3.8 %, Fibrinogen:121 mg/dL, Ca++:8.3 mg/dL, Mg++:1.5 mg/dL,\n PO4:2.2 mg/dL\n Imaging: none\n Microbiology: ctx knee final negative\n Assessment and Plan\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n .H/O CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. s/p thrombectomy \n a. on Heparin now- transition to Lovenox today\n b at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures negative, so stopped antibiotics\n c. Steroids not started. Patient has improved knee mobility and\n decreased knee pain. Will address need for steroids with patient after\n IR procedure.\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following. Will discuss with rheum about long term\n colchicine use\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.2: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.1\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: repleted K, Mg\n Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to floor pending procedure, will email\n PCP.\n \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 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": "2107-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688859, "text": "Chief Complaint:\n 24 Hour Events:\n SHEATH - STOP 03:00 PM\n -s/p LUE parital thrombectomy by IR. Doing well post-procedure. Abx\n d/c'd. Restarted heparin drip at weight based dosing, plan to start\n lovenox in AM, which he will be on for the next 3 months for\n anticoagulation. Resumed diet and activity. Called out, waiting on\n bed.\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Cefazolin - 08:50 AM\n Vancomycin - 10:00 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other medications:\n Other medications:\n 1000 mL NS 4. Colchicine 5. Heparin 6. Hydrocodone-Acetaminophen 7.\n Lisinopril 8. Loperamide\n 9. Magnesium Sulfate 10. Ondansetron ODT 11. Pantoprazole 12.\n Pneumococcal Vac Polyvalent 13. Potassium Chloride\n 14. Potassium Chloride 15. Prochlorperazine 16. Sodium Chloride 0.9%\n Flush\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: +pain at catheter site in left arm but decreased\n left hand erythema; decreased left knee pain; no SOB, no CP\n Flowsheet Data as of 07:28 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: 36.7\nC (98\n HR: 68 (66 - 103) bpm\n BP: 143/84(97) {107/58(69) - 157/87(104)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,846 mL\n 1,059 mL\n PO:\n 640 mL\n 240 mL\n TF:\n IVF:\n 3,206 mL\n 819 mL\n Blood products:\n Total out:\n 1,900 mL\n 1,400 mL\n Urine:\n 1,900 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n -341 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Gen: NAD\n Neck: + SCV edema on left\n CV: rrr no murmurs, nl s1/s2\n Pulm: CTA b/l\n abd: +BS, soft, NTND\n Ext: continued edema left arm and hand, no erythema, +pulses, nl\n sensation and motor\n Labs / Radiology\n 174 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.0 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 25.8 %\n 3.7 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n 01:16 AM\n WBC\n 5.4\n 3.7\n Hct\n 27.0\n 26.2\n 25.8\n Plt\n 183\n 174\n Cr\n 1.2\n 1.1\n Glucose\n 102\n 122\n Other labs: PT / PTT / INR:16.8/137.7/1.5, ALT / AST:31/68, Alk Phos /\n T Bili:62/0.3, Differential-Neuts:55.2 %, Lymph:30.4 %, Mono:10.3 %,\n Eos:3.8 %, Fibrinogen:121 mg/dL, Ca++:8.3 mg/dL, Mg++:1.5 mg/dL,\n PO4:2.2 mg/dL\n Imaging: none\n Microbiology: ctx knee final negative\n Assessment and Plan\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n .H/O CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. s/p thrombectomy \n a. transitioned to Lovenox from Heparin\n b seen by and spoke with oncologist; determined\n can still use current port\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures negative, so stopped antibiotics\n c. Steroids not started. Patient has improved knee mobility and\n decreased knee pain.\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following. Will discuss with rheum about long term\n colchicine use\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.2: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.1\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: repleted K, Mg\n Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to floor pending procedure, will email\n PCP.\n \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: on Heparin to Lovenox\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: d/c today ; has follow-up, PCP aware will need PA for\n lovenox\n" }, { "category": "Nursing", "chartdate": "2107-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688853, "text": "75 y.o male with a PMHx: Stage 3B colon Ca, HTN. Gout, stage 3 disease\n kidney disease, AAA. Recently diagnosed stage III B colon CA, s/p\n right colectomy being tx with adjuvant chemo (C1D23 FOLFOX last\n dose .) through left subclavian portacath.\n Presented with L neck discomfort x 2 days found to have L arm swelling.\n US + for LIJ clot and sent to \ns ED on . Pt denies SOB, CP,\n or recent surgery. Pt has L subclavian portacath. CTA in ED negative\n for SVC syndrome. Guiac negative and negative head CT. Doppler u/s\n positive for LIJ clot. MR venogram confirmed left subclavian, IJ and\n brachiocephalic thromboses.\n : IR attempted clot removal and was not successful patient\n transferred to ICU for close monitoring during tPA and heparin\n infusion.\n : IR attempt X2 today for LUE venogram and angioplasty . Returned\n to CCU with heparin gtt per weight-based protocol & NS @ 100ml/hr.\n Heparin shut off at 1000. Wife gave dose of lovanox. Dishcharge\n planning completed. Pt received med teaching and scripts. His visiting\n nurse and will see pt tomorrow. Pt feels ready to go. All\n followup appointments given. See Discharge plan and page 2 for\n details.\n" }, { "category": "Physician ", "chartdate": "2107-07-13 00:00:00.000", "description": "ICU Attending Addendum", "row_id": 688849, "text": "Critical Care Attending\n I saw and examined Mr. with the ICU team on rounds; today\n ICU note reflects my input. Tolerated repeat IR procedure without\n complications yesterday. Seen by line service regarding issues of\n continuing use of port-a-cath. Discussed with IR and with Dr.\n ; will anticipate discharge on LMWH. Discussed with Mr.\n and all questions answered. He has close follow-up with Dr.\n .\n" }, { "category": "Nursing", "chartdate": "2107-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688852, "text": "75 y.o male with a PMHx: Stage 3B colon Ca, HTN. Gout, stage 3 disease\n kidney disease, AAA. Recently diagnosed stage III B colon CA, s/p\n right colectomy being tx with adjuvant chemo (C1D23 FOLFOX last\n dose .) through left subclavian portacath.\n Presented with L neck discomfort x 2 days found to have L arm swelling.\n US + for LIJ clot and sent to \ns ED on . Pt denies SOB, CP,\n or recent surgery. Pt has L subclavian portacath. CTA in ED negative\n for SVC syndrome. Guiac negative and negative head CT. Doppler u/s\n positive for LIJ clot. MR venogram confirmed left subclavian, IJ and\n brachiocephalic thromboses.\n : IR attempted clot removal and was not successful patient\n transferred to ICU for close monitoring during tPA and heparin\n infusion.\n : IR attempt X2 today for LUE venogram and angioplasty . Returned\n to CCU with heparin gtt per weight-based protocol & NS @ 100ml/hr.\n Heparin shut off at 1000. Wife gave dose of lovanox. Dishcharge\n planning completed. Pt received med teaching and scripts. His visiting\n nurse and will see pt tomorrow. Pt feels ready to go. All\n followup appointments given.\n" }, { "category": "Nursing", "chartdate": "2107-07-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688779, "text": "75 y.o male with a PMHx: Stage 3B colon Ca, HTN. Gout, stage 3 disease\n kidney disease, AAA. Recently diagnosed stage III B colon CA, s/p\n right colectomy being tx with adjuvant chemo (C1D23 FOLFOX last\n dose .) through left subclavian portacath.\n Presented with L neck discomfort x 2 days found to have L arm swelling.\n US + for LIJ clot and sent to \ns ED on . Pt denies SOB, CP,\n or recent surgery. Pt has L subclavian portacath. CTA in ED negative\n for SVC syndrome. Guiac negative and negative head CT. Doppler u/s\n positive for LIJ clot. MR venogram confirmed left subclavian, IJ and\n brachiocephalic thromboses.\n : IR attempted clot removal and was not successful patient\n transferred to ICU for close monitoring during tPA and heparin\n infusion.\n : IR attempt X2 today for LUE venogram and angioplasty . Returned\n to CCU with heparin gtt per weight-based protocol & NS @ 100ml/hr.\n Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. L arm continues swollen,\n good CSM, radial pulses palp, capillary refill wnl. Pt continues on\n bedrest with LUE kept straight and HOB no greater than 30 degrees. Pt\n with some c/o discomfort in L foot/knee r/t gout.\n Action:\n Cont. heparin gtt per weight-based protocol. 0130 PTT= 137.7. Titrated\n heparin per protocol. Freq assessment of left arm for pulses & CSM.\n Response:\n Per report, pt with partial improvement in thrombis. LUE continues\n swollen with palp pulses and good CSM. Some c/o tenderness at site, no\n c/o pain, declines pain meds. Pt on heparin gtt at 1150 units/hr.\n Previous sheath site dressing with no bleeding, redness, or swelling.\n Plan:\n Continue with heparin gtt, obtain PTT at 1000. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n Cont. to assess previous Left brachial sheath placement\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Thrombis r/t portacath as above. Pt still receiving chemo.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. as pt initially scheduled\n for chemo tomorrow per pt.\n MD aware of K=3.0, awaiting orders.\n Plan: Patient was called-out to floor @ 1900. Start lovenox in am\n and discharge home. Patient strongly would like to be discharged by\n noon on .\n RN CCRN\n" }, { "category": "Physician ", "chartdate": "2107-07-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688790, "text": "Chief Complaint:\n 24 Hour Events:\n SHEATH - STOP 03:00 PM\n -s/p LUE thrombectomy by IR. Doing well post-procedure. Abx d/c'd.\n Restarted heparin drip at weight based dosing, plan to start lovenox in\n AM, which he will be on for the next 3 months for anticoagulation.\n Resumed diet and activity. Called out, waiting on bed.\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Cefazolin - 08:50 AM\n Vancomycin - 10:00 AM\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Other medications:\n Other medications:\n 1000 mL NS 4. Colchicine 5. Heparin 6. Hydrocodone-Acetaminophen 7.\n Lisinopril 8. Loperamide\n 9. Magnesium Sulfate 10. Ondansetron ODT 11. Pantoprazole 12.\n Pneumococcal Vac Polyvalent 13. Potassium Chloride\n 14. Potassium Chloride 15. Prochlorperazine 16. Sodium Chloride 0.9%\n Flush\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 07:28 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: 36.7\nC (98\n HR: 68 (66 - 103) bpm\n BP: 143/84(97) {107/58(69) - 157/87(104)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 3,846 mL\n 1,059 mL\n PO:\n 640 mL\n 240 mL\n TF:\n IVF:\n 3,206 mL\n 819 mL\n Blood products:\n Total out:\n 1,900 mL\n 1,400 mL\n Urine:\n 1,900 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n -341 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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 174 K/uL\n 8.9 g/dL\n 122 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 3.0 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 25.8 %\n 3.7 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n 01:16 AM\n WBC\n 5.4\n 3.7\n Hct\n 27.0\n 26.2\n 25.8\n Plt\n 183\n 174\n Cr\n 1.2\n 1.1\n Glucose\n 102\n 122\n Other labs: PT / PTT / INR:16.8/137.7/1.5, ALT / AST:31/68, Alk Phos /\n T Bili:62/0.3, Differential-Neuts:55.2 %, Lymph:30.4 %, Mono:10.3 %,\n Eos:3.8 %, Fibrinogen:121 mg/dL, Ca++:8.3 mg/dL, Mg++:1.5 mg/dL,\n PO4:2.2 mg/dL\n Imaging: none\n Microbiology: ctx knee final negative\n Assessment and Plan\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n .H/O CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. s/p thrombectomy \n a. on Heparin now- transition to Lovenox today\n b at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures negative, so stopped antibiotics\n c. Steroids not started. Patient has improved knee mobility and\n decreased knee pain. Will address need for steroids with patient after\n IR procedure.\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following. Will discuss with rheum about long term\n colchicine use\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.2: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.1\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: repleted K, Mg\n Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to floor pending procedure, will email\n PCP.\n \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 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": "2107-07-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688562, "text": "Chief Complaint: L subclavian clot\n 24 Hour Events:\n SHEATH - START 07:05 PM\n - No overnight events\n - Knee pain stable\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Cefazolin - 02:03 AM\n Infusions:\n Alteplase (TPA) - 0.25 mg/hour\n Heparin Sodium - 300 units/hour\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 07:37 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 (97.5\n HR: 78 (64 - 89) bpm\n BP: 135/79(92) {124/66(80) - 155/86(102)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 461 mL\n 972 mL\n PO:\n TF:\n IVF:\n 461 mL\n 972 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, L knee swelling, no warmth or redness; LUE\n swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): AAO X3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 183 K/uL\n 9.0 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 109 mEq/L\n 142 mEq/L\n 26.2 %\n 5.4 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n WBC\n 5.4\n Hct\n 27.0\n 26.2\n Plt\n 183\n Cr\n 1.2\n Glucose\n 102\n Other labs: PT / PTT / INR:15.8/38.1/1.4, ALT / AST:38/75, Alk Phos / T\n Bili:64/0.3, Fibrinogen:131 mg/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram today\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Abx until cultures finalized\n c. Steroids not started yesterday. Give Prednisone 30mg po today\n then 20mg qday x1 then 10mg po qday x1 then stop\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.2\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: replete phose\n ICU Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688679, "text": "Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Received pt from\n IR with Heparin gtt 300 units/hr.\n Plan:\n Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Physician ", "chartdate": "2107-07-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688570, "text": "Chief Complaint: L subclavian clot\n 24 Hour Events:\n SHEATH - START 07:05 PM\n - No overnight events\n - Knee pain stable\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Cefazolin - 02:03 AM\n Infusions:\n Alteplase (TPA) - 0.25 mg/hour\n Heparin Sodium - 300 units/hour\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 07:37 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 (97.5\n HR: 78 (64 - 89) bpm\n BP: 135/79(92) {124/66(80) - 155/86(102)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 461 mL\n 972 mL\n PO:\n TF:\n IVF:\n 461 mL\n 972 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, L knee swelling, no warmth or redness; LUE\n swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): AAO X3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 183 K/uL\n 9.0 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 109 mEq/L\n 142 mEq/L\n 26.2 %\n 5.4 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n WBC\n 5.4\n Hct\n 27.0\n 26.2\n Plt\n 183\n Cr\n 1.2\n Glucose\n 102\n Other labs: PT / PTT / INR:15.8/38.1/1.4, ALT / AST:38/75, Alk Phos / T\n Bili:64/0.3, Fibrinogen:131 mg/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram today\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Abx until cultures finalized\n c. Steroids not started yesterday. Give Prednisone 30mg po today\n then 20mg qday x1 then 10mg po qday x1 then stop\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.2\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: replete phose\n ICU Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2107-07-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 688482, "text": "TITLE:\n Chief Complaint: left arm swelling, left face swelling\n HPI:\n 75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days found\n to have L arm swelling. US + for LIJ clot and sent to ED. Otherwise no\n SOB, CP. No sx. H/o L subclavian port. CTA in ED negative for SVC\n syndrome. Guiac negative and negative head CT. C1D23 FOLFOX with last\n dose on . IR attempted clot removal and was not\n successful patient transferred to ICU for close monitoring during tPA\n and heparin infusion.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 300 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Oncologic History:\n stage IIIB colon cancer with 1 LN/9 +ve in when he\n presented with 6 months of of stomach discomfort, bloating,\n distension and gas.\n Started FOLFOX on \n HTN\n Gout\n Stage 3 disease kidney disease\n Abdominal aortic aneurysm\n siblings with colon ca at age 50\n Occupation:\n Drugs: no\n Tobacco: remote\n Alcohol: 2 glasses of wine with dinner\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation, one loose BM per day\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, left knee\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:59 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: 36.4\nC (97.6\n HR: 71 (71 - 86) bpm\n BP: 138/78(92) {138/78(92) - 155/86(102)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 200 mL\n PO:\n TF:\n IVF:\n 200 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 200 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, L port in place with mild\n erythema, non-tender\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n No(t) Systolic)\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 Abdominal: Soft, Non-tender, Bowel sounds present, mid-line well healed\n scar\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing, left upper extremity swelling, and mild on left neck and\n inferior aspect of face, left knee with mild erythema, increased\n warmth, ttp with small effusion, limited ROM by 15 degrees\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, reason for admit, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n MR venogram obtained per IR, showing clot in LIJ, brachiocephalic and\n subclavian\n 3:37 pm JOINT FLUID Source: Knee.\n GRAM STAIN (Final ):\n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n 258\n 10.8\n 144\n 1.3\n 13\n 22\n 107\n 3.8\n 141\n 31.8\n 7.6\n [image002.jpg]\n PT: 12.7\n PTT: 53.0\n INR: 1.1\n Assessment and Plan\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram in AM\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Abx until am and cx finalized\n c. If joint cx neg, consider starting steroids to help with\n gout, solumedrol 40 mg IV *1, prednisone taper\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Left foot numbness, arthralgia: Foot x-ray negative, cont to\n monitor\n 5) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 6) HTN: Cont lisinopril\n 7) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor Cr\n 8) Nausea: likely chemo SE, cont compazine prn, standing zofran\n a. Start ppi\n 9) Hyperglycemia: trend, consider HISS\n ICU Care\n Nutrition:\n Glycemic Control: Sips pending reimaging\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt, tPA drip)\n Stress ulcer: started ppi\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2107-07-12 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 688483, "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 75 y.o M with recently diagnosed stage III B colon CA, s/p right\n colectomy being tx with adjuvant chemo (C1D23 FOLFOX last dose\n .) through left subclavian port, admitted for evaluation of L\n neck swelling and discomfort x 2 days. Doppler u/s positive for LIJ\n clot. MR venogram confirmed left subclavian, IJ and brachiocephalic\n thromboses.\n Denies SOB, CP. CTA in ED negative for SVC syndrome. Guiac negative and\n CT head negative. Complains of left knee pain x several days. Denies\n fever.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 300 units/hour\n Other ICU medications:\n Other medications:\n reviewed\n Past medical history:\n Family history:\n Social History:\n Stage 3B colon Ca, HTN. Gout, stage 3 disease kidney disease, AAA\n siblings with colon ca at age 50\n Occupation:\n Drugs:\n Tobacco: None\n Alcohol: Occasional\n Other: LIves with wife\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, Edema\n Respiratory: No(t) Cough\n Musculoskeletal: Joint pain, Left knee, limited ROM\n Flowsheet Data as of 12:01 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: 74 (71 - 86) bpm\n BP: 136/80(93) {136/78(92) - 155/86(102)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 448 mL\n PO:\n TF:\n IVF:\n 448 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 448 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), 1/6 SEM\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present),\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant/lat)\n Abdominal: Soft, Non-tender, Bowel sounds present, well healed scar\n midline\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing, LUE swelling, catheter in upper arm, Left knee with edema,\n limited flexion to ~45 degrees, mildly tender to palpation\n Musculoskeletal: No(t) Muscle wasting, Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 258\n 27.0 %\n 134\n 1.3\n 7.1\n [image002.jpg]\n 10:29 PM\n Hct\n 27.0\n Other labs: PT / PTT / INR:15.8//1.4, Fibrinogen:168 mg/dL\n Imaging: MR venogram - clot in LIJ, brachiocephalic and subclavian\n Microbiology: GRAM STAIN (Final ): 4+ polys, no microorgs.\n Final cx no growth\n Assessment and Plan\n 75 yr old colon ca, s/p resection now getting FOLFOX adjuvant chemo,\n admitted for LUE clot involving left S/c, IJ and b/c veins, likely\n caused by left portacath. Went for IR clot removal which was not\n successful, now has infusion of TPA/heparin via left brachiocephalic\n catheter. Plan is to continue this overnight and repeat a venogram in\n AM. Will need to consider resiting tunneled catheter.\n Left knee pain likely due to gout. Improving on colchicine but also\n being treated empirically for septic left knee with Vanc/Cefazolin.\n Initial tap >60,000 WBC, prelim culture negative. Rheumatology\n following - due to large number of PMN started on IV ABx until culture\n returns, however crystals seen suggesting gout. Solumedrol 40 mg IV X 1\n then consider Prednisone taper starting tomorrow\n Rest of plan as outlined in Dr. \ns note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: None, TPA/heparin infusion in LUE)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 38 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688716, "text": "75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days found\n to have L arm swelling. US + for LIJ clot and sent to ED. Otherwise no\n SOB, CP. No sx. H/o L subclavian port. CTA in ED negative for SVC\n syndrome. Guiac negative and negative head CT. C1D23 FOLFOX with last\n dose on . IR attempted clot removal and was not\n successful patient transferred to ICU for close monitoring during tPA\n and heparin infusion.\n Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Scant amount blood\n noted on dsg, area slightly bruised, LUE continues swollen with palp\n pulses and good CSM. Some c/o tenderness at site, no c/o pain, declines\n pain meds. Received pt from IR with Heparin gtt 300 units/hr. After\n multiple discussions with MICU Team/IR, pt on heparin gtt at 1500\n units/hr.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo. Pt OOB this eve and had BM in toilet-not visualized by RN.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688717, "text": "75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days found\n to have L arm swelling. US + for LIJ clot and sent to ED. Otherwise no\n SOB, CP. No sx. H/o L subclavian port. CTA in ED negative for SVC\n syndrome. Guiac negative and negative head CT. C1D23 FOLFOX with last\n dose on . IR attempted clot removal and was not\n successful patient transferred to ICU for close monitoring during tPA\n and heparin infusion.\n 75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days found\n to have L arm swelling. US + for LIJ clot and sent to ED. Otherwise no\n SOB, CP. No sx. H/o L subclavian port. CTA in ED negative for SVC\n syndrome. Guiac negative and negative head CT. C1D23 FOLFOX with last\n dose on . IR attempted clot removal and was not\n successful patient transferred to ICU for close monitoring during tPA\n and heparin infusion.\n Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Scant amount blood\n noted on dsg, area slightly bruised, LUE continues swollen with palp\n pulses and good CSM. Some c/o tenderness at site, no c/o pain, declines\n pain meds. Received pt from IR with Heparin gtt 300 units/hr. After\n multiple discussions with MICU Team/IR, pt on heparin gtt at 1500\n units/hr.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo. Pt OOB this eve and had BM in toilet-not visualized by RN.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688718, "text": "75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days found\n to have L arm swelling. US + for LIJ clot and sent to ED. Otherwise no\n SOB, CP. No sx. H/o L subclavian port. CTA in ED negative for SVC\n syndrome. Guiac negative and negative head CT. C1D23 FOLFOX with last\n dose on . IR attempted clot removal and was not\n successful patient transferred to ICU for close monitoring during tPA\n and heparin infusion.\n 75 y.o M with recently diagnosed stage III B colon CA, s/p right\n colectomy being tx with adjuvant chemo (C1D23 FOLFOX last dose\n .) through left subclavian port, admitted for evaluation of L\n neck swelling and discomfort x 2 days. Doppler u/s positive for LIJ\n clot. MR venogram confirmed left subclavian, IJ and brachiocephalic\n thromboses.\n Denies SOB, CP. CTA in ED negative for SVC syndrome. Guiac negative and\n CT head negative. Complains of left knee pain x several days. Denies\n fever.\n Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Scant amount blood\n noted on dsg, area slightly bruised, LUE continues swollen with palp\n pulses and good CSM. Some c/o tenderness at site, no c/o pain, declines\n pain meds. Received pt from IR with Heparin gtt 300 units/hr. After\n multiple discussions with MICU Team/IR, pt on heparin gtt at 1500\n units/hr.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo. Pt OOB this eve and had BM in toilet-not visualized by RN.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688720, "text": "75 y.o male with a PMHx: Stage 3B colon Ca, HTN. Gout, stage 3 disease\n kidney disease, AAA. Recently diagnosed stage III B colon CA, s/p\n right colectomy being tx with adjuvant chemo (C1D23 FOLFOX last\n dose .) through left subclavian portacath.\n Presented with L neck discomfort x 2 days found to have L arm swelling.\n US + for LIJ clot and sent to \ns ED on . Pt denies SOB, CP,\n or recent surgery. Pt has L subclavian portacath. CTA in ED negative\n for SVC syndrome. Guiac negative and negative head CT. Doppler u/s\n positive for LIJ clot. MR venogram confirmed left subclavian, IJ and\n brachiocephalic thromboses.\n : IR attempted clot removal and was not successful patient\n transferred to ICU for close monitoring during tPA and heparin\n infusion.\n : IR attempt X2 today for LUE venogram and angioplasty . Returned\n to CCU with heparin gtt per weight-based protocol & NS @ 100ml/hr.\n Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. L arm continues swollen,\n good CSM, radial pulses palp, capillary refill wnl. Pt continues on\n bedrest with LUE kept straight and HOB no greater than 30 degrees. Pt\n with some c/o discomfort in L foot/knee r/t gout.\n Action:\n Cont. heparin gtt per weight-based protocol. Freq assessment of left\n arm for pulses & CSM.\n Response:\n Per report, pt with partial improvement in thrombis. LUE continues\n swollen with palp pulses and good CSM. Some c/o tenderness at site, no\n c/o pain, declines pain meds. Pt on heparin gtt at 1500 units/hr.\n Previous sheath site dressing with no bleeding, redness, or swelling.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n Cont. to assess previous Left brachial sheath placement\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Thrombis r/t portacath as above. Pt still receiving chemo.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. as pt initially scheduled\n for chemo tomorrow per pt.\n Plan: Patient was called-out to floor @ 1900, awaited bed\n overnight. Start lovenox in am and discharge home.\n RN CCRN\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688715, "text": "Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Scant amount blood\n noted on dsg, area slightly bruised, LUE continues swollen with palp\n pulses and good CSM. Some c/o tenderness at site, no c/o pain, declines\n pain meds. Received pt from IR with Heparin gtt 300 units/hr. After\n multiple discussions with MICU Team/IR, pt on heparin gtt at 1500\n units/hr.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo. Pt OOB this eve and had BM in toilet-not visualized by RN.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Physician ", "chartdate": "2107-07-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 688481, "text": "TITLE:\n Chief Complaint: left arm swelling, left face swelling\n HPI:\n 75 y.o M with recently diagnosed stage III B colon CA, recently\n started on chemotherapy presents with L neck discomfort x 2 days\n found to have L arm swelling. US + for LIJ clot and sent to ED.\n Otherwise no SOB, CP. No sx. H/o L subclavian port. CTA in ED\n negative for SVC syndrome. Guiac negative and negative head CT\n C1D23 FOLFOX with last dose on .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 300 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Oncologic History:\n stage IIIB colon cancer with 1 LN/9 +ve in when he\n presented with 6 months of of stomach discomfort, bloating,\n distension and gas.\n Started FOLFOX on \n HTN\n Gout\n Stage 3 disease kidney disease\n Abdominal aortic aneurysm\n siblings with colon ca at age 50\n Occupation:\n Drugs: no\n Tobacco: remote\n Alcohol: 2 glasses of wine with dinner\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation, one loose BM per day\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, left knee\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:59 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: 36.4\nC (97.6\n HR: 71 (71 - 86) bpm\n BP: 138/78(92) {138/78(92) - 155/86(102)} mmHg\n RR: 17 (16 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 200 mL\n PO:\n TF:\n IVF:\n 200 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 200 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, L port in place with mild\n erythema, non-tender\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n No(t) Systolic)\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 Abdominal: Soft, Non-tender, Bowel sounds present, mid-line well healed\n scar\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing, left upper extremity swelling, and mild on left neck and\n inferior aspect of face, left knee with mild erythema, increased\n warmth, ttp with small effusion, limited ROM by 15 degrees\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, reason for admit, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n MR venogram obtained per IR, showing clot in LIJ, brachiocephalic and\n subclavian\n 3:37 pm JOINT FLUID Source: Knee.\n GRAM STAIN (Final ):\n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): NO GROWTH.\n [image002.jpg]\n Assessment and Plan\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram in AM\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC.\n a. Abx until am and cx finalized\n b. If joint cx neg, consider starting steroids to help with gout,\n solumedrol 40 mg IV *1, prednisone taper\n c. Cont colchicine, naproxen and monitor Cr\n d. Rheum following\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n 4) Left foot numbness, arthralgia\n 5) chronic normocytic anemia\n 6) HTN\n 7) CRI: Last Cr 1.3\n #LIJ Deep venous thrombosis: MR venogram obtained per IR, showing clot\n in LIJ, brachiocephalic and subclavian -> plan for clot lysis today.\n -F/U IR recs post procedure\n .\n #L knee pain, swelling and warmth: Ultrasound demonstrated no \n cyst (recent history). Differential includes septic joint vs. gout.\n Most likely gout based on known PMH and no fevers, chills. Rheumatology\n consulted: due to large number of PMN started on IV ABx until culture\n returned, however crystals seen suggesting gout. Pain not improving\n with naproxen.\n -Colchicine increased to 0.6 mg qd\n -naproxen (monitor creatinine)\n -per rheum: Solumedrol 40 mg IV X 1, stop abx in am, predisone taper\n -appreciate rheum recs\n .\n #Stage III B Colon CA: C1D23 FOLFOX\n - next chemo due \n - Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week given need for IR procedure on monday and strong\n likelihood that port will need to be removed (involved in L clot).\n .\n #L foot numbness, athralgias and duskiness:\n - foot X ray showed no fracture or dislocation\n .\n # chronic normocytic anemia: stable, likely AKD\n -B12, folate and TSH wnl\n .\n #HTN:\n - Cont lisinopril 5 mg: hold for sbp <110\n .\n #CRI: Last Cr 1.3\n - renally dose medications\n - monitor closely due to naproxen - will hold when patient returns from\n IR procedure\n - continue low dose lisnopril.\n .\n #FEN/GI: regular diet, replete lytes as needed\n .\n #Prophylaxis: heparin drip on hold, no ppi currently\n .\n #Access: peripherals, L port\n .\n #Code status: FULL code\n ICU Care\n Nutrition:\n Glycemic Control: Sips pending reimaging\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt, tPA drip)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2107-07-12 00:00:00.000", "description": "Resident / Attending Notes", "row_id": 688711, "text": "Chief Complaint: L subclavian, IJ and brachiocephalic clot\n 24 Hour Events:\n SHEATH - START 07:05 PM\n - No overnight events\n - Knee pain stable\n - This AM pt frustrated with wait for IR, wanted to leave AMA, but\n decided to stay after talking to nurses and housestaff\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Cefazolin - 02:03 AM\n Infusions:\n Alteplase (TPA) - 0.25 mg/hour\n Heparin Sodium - 300 units/hour\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 07:37 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 (97.5\n HR: 78 (64 - 89) bpm\n BP: 135/79(92) {124/66(80) - 155/86(102)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 461 mL\n 972 mL\n PO:\n TF:\n IVF:\n 461 mL\n 972 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, L knee swelling, no warmth or redness; LUE\n swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): AAO X3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 183 K/uL\n 9.0 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 109 mEq/L\n 142 mEq/L\n 26.2 %\n 5.4 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n WBC\n 5.4\n Hct\n 27.0\n 26.2\n Plt\n 183\n Cr\n 1.2\n Glucose\n 102\n Other labs: PT / PTT / INR:15.8/38.1/1.4, ALT / AST:38/75, Alk Phos / T\n Bili:64/0.3, Fibrinogen:131 mg/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram today\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures negative, so stopped antibiotics\n c. Steroids not started yesterday. Patient has improved knee\n mobility and decreased knee pain. Will address need for steroids with\n patient after IR procedure.\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following. Will discuss with rheum about long term\n colchicine use\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.2\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: replete phose\n ICU Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to floor pending procedure, will email\n PCP.\n Protected Section ------\n Critical Care Attending\n I saw and examined Mr. with the ICU team on rounds; Dr.\n \ns note reflects my input. Tolerated TPA infusion and to go back\n to IR today. If tolerates, would be reasonable to consider transfer to\n floor. Discussed with Mr. and all questions answered.\n ------ Protected Section Addendum Entered By: , MD\n on: 21:16 ------\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688707, "text": "Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Pt sent to IR at approx 1230 for LUE venogram and angioplasty.\n Response:\n Per report, pt with partial improvement in thrombis. Scant amount blood\n noted on dsg, area slightly bruised, LUE continues swollen with palp\n pulses and good CSM. Some c/o tenderness at site, no c/o pain, declines\n pain meds. Received pt from IR with Heparin gtt 300 units/hr. After\n multiple discussions with MICU Team/IR, pt on heparin gtt at 1500\n units/hr.\n Plan:\n Continue with heparin gtt, obtain PTT at 0100. Anticipate pt to start\n on lovenox injections in am as MICU MD. Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Pt monitored. Thrombis r/t portacath as above. Pt still receiving\n chemo. Pt OOB this eve and had BM in toilet-not visualized by RN.\n Response:\n Thrombis r/t portacath as above.\n Plan:\n Continue to monitor. ? next date of chemo tx. As pt initially scheduled\n for chemo tomorrow per pt.\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 688517, "text": "Thrombosis\n Assessment:\n Transferred from IR for overnoc observation with L brachiocephalic\n venous sheath in place. Heparin and TPA infusing through sheath.\n Alert and oreinted. Mild discomfort in L knee r/t gout. Lungs clear.\n Palp pedal pulses. L arm sheath with small amount sang drainage.\n Strong radial and ulnar pulses. NPO overnoc. Bedrest with HOB 30\n degrees. On vanco and cefazolin. Afebrile.\n Action:\n monitored, fibrinogen monitored as ordered and TPA decreased per\n order. Pt declines pain meds for knee discomfort. Sheath dressing\n reinforced. Armboard applied to L arm. NPO, bedrest maintained.\n Response:\n pt slept on and off overnoc. States discomfort is tolerable.\n Expressing frustration r/t NPO status and bedrest. Expressing anxiety\n r/t possibility of removal of port a cath. Afebrile, vital signs\n stable. L arm sheath intact with strong peripheral pulses.\n Plan:\n continue to monitor. Continue heparin infusion at current rate.\n Continue TPA infusion and recheck fibrinogen at 0930. plan to return\n to IR today for further attempt at angioplasty/embolectomy.\n" }, { "category": "Physician ", "chartdate": "2107-07-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 688626, "text": "Chief Complaint: L subclavian, IJ and brachiocephalic clot\n 24 Hour Events:\n SHEATH - START 07:05 PM\n - No overnight events\n - Knee pain stable\n - This AM pt frustrated with wait for IR, wanted to leave AMA, but\n decided to stay after talking to nurses and housestaff\n Allergies:\n Aspirin\n Hives;\n Shellfish Derived\n Hives;\n Last dose of Antibiotics:\n Vancomycin - 10:55 PM\n Cefazolin - 02:03 AM\n Infusions:\n Alteplase (TPA) - 0.25 mg/hour\n Heparin Sodium - 300 units/hour\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 07:37 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 (97.5\n HR: 78 (64 - 89) bpm\n BP: 135/79(92) {124/66(80) - 155/86(102)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 461 mL\n 972 mL\n PO:\n TF:\n IVF:\n 461 mL\n 972 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, L knee swelling, no warmth or redness; LUE\n swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): AAO X3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 183 K/uL\n 9.0 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 17 mg/dL\n 109 mEq/L\n 142 mEq/L\n 26.2 %\n 5.4 K/uL\n [image002.jpg]\n 10:29 PM\n 03:22 AM\n WBC\n 5.4\n Hct\n 27.0\n 26.2\n Plt\n 183\n Cr\n 1.2\n Glucose\n 102\n Other labs: PT / PTT / INR:15.8/38.1/1.4, ALT / AST:38/75, Alk Phos / T\n Bili:64/0.3, Fibrinogen:131 mg/dL, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n 1) LUE DVT: precipitant was likely port-a-cath, pt also with\n recent hx malignancy. IR unable to remove clot .\n a. tPA and heparin infuse into clot, recheck venogram today\n b. appreciate IR continued recommendations\n c. at some point, pt will likely need port removal.\n 2) L Knee Pain: s/p tap with no growth to date. Gout vs septic,\n initial tap >60,000 WBC. On vanc/cefazolin.\n a. Percocet for pain\n b. Cultures negative, so stopped antibiotics\n c. Steroids not started yesterday. Patient has improved knee\n mobility and decreased knee pain. Will address need for steroids with\n patient after IR procedure.\n d. Cont colchicine, naproxen and monitor Cr\n e. Rheum following. Will discuss with rheum about long term\n colchicine use\n 3) Stage III B Colon Ca: C1D23 FOLFOX\n a. Chemo on hold until assess ability to use port given clot,\n Per primary oncologist, Dr. , patient will delay adjuvant\n chemo by one week to \n 4) Chronic normocytic anemia: felt due to anemia of chronic\n disease. TSH, B12, folate wnl.\n 5) HTN: Cont lisinopril\n 6) CRI: Last Cr 1.3: Hold naproxen given IR procedure, monitor\n Cr. Improved today at 1.2\n 7) Nausea: likely chemo SE, cont compazine prn, standing zofran\n 8) Hyperglycemia: trend, consider HISS\n 9) FEN: replete phose\n ICU Care\n Nutrition:\n Comments: sips until procedure\n Glycemic Control: Blood sugar well controlled\n Lines:\n Sheath - 07:05 PM\n 20 Gauge - 07:06 PM\n 22 Gauge - 07:07 PM\n Prophylaxis:\n DVT: (Heparin IV and alteplase)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to floor pending procedure, will email\n PCP.\n" }, { "category": "Nursing", "chartdate": "2107-07-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 688606, "text": "Deep Venous Thrombosis (DVT), Upper extremity/thrombosis\n Assessment:\n Pt with clot in LIJ likely from portacath. Received pt with TPA\n infusing at 0.25 mg/hr and Heparin 300 units/hr. L brachiocephalic\n venous sheath in place. L arm continues swollen, good CSM, radial\n pulses palp, capillary refill wnl. L arm sheath with small amount of\n serous drainage. Pt continues on bedrest with LUE kept straight and HOB\n no greater than 30 degrees. Pt with some c/o discomfort in L foot/knee\n r/t gout.\n Action:\n Fibrinogen level sent at 10 am. Pt sent to IR at Pt declined pain\n medication for knee/foot discomfort.\n Response:\n Fibrinogen level 113, TPA continues at 0.25 mg/hr and heparin 300\n units/hr.\n Plan:\n Continue to monitor pulses.\n .H/O cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with hx of stage III B colon ca.\n Action:\n Response:\n Plan:\n" }, { "category": "ECG", "chartdate": "2107-07-11 00:00:00.000", "description": "Report", "row_id": 253330, "text": "Sinus rhythm. Baseline artifact. Compared to the previous tracing of \nthe tracing remains normal without diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-12 00:00:00.000", "description": "PTA VENOUS", "row_id": 1089602, "text": " 12:56 PM\n UNILAT SUBCLAV Clip # \n Reason: venogram upper extremity, left, to assess clot burden\n Admitting Diagnosis: LEFT IJ CLOT\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * PTA VENOUS PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE INTRO CATH SVC/IVC *\n * PTA VENOUS PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE EXTREM UNILAT VENOGRAPHY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with clot throughout left upper extremity venous system related\n to a port-a-cath, please reassess for effects of tPA and heparin on this clot\n REASON FOR THIS EXAMINATION:\n venogram upper extremity, left, to assess clot burden\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left internal jugular and subclavian venous thrombus with left arm\n swelling.\n\n COMPARISON: Comparison is made to fluoroscopic images obtained one day\n earlier.\n\n PHYSICIANS: Study was performed by Dr. , Dr. and Dr. .\n\n FINDINGS: Prior to arrival in the angiography suite, written informed consent\n for the procedure was obtained and a preprocedure timeout was performed upon\n arrival using name, date of birth, and medical record number as identifiers.\n Throughout the study, moderate sedation was provided by administering divided\n doses of fentanyl and Versed throughout the total intraservice time of 30\n minutes during which the patient's hemodynamic parameters were continuously\n monitored. In total, the patient received 50 mcg of fentanyl and 2 mg of\n Versed.\n\n The patient presented with a pre-existing TPA infusion catheter in the left\n brachiocephalic vein. wire was advanced through this pre-existing\n catheter and passed into the IVC under fluoroscopic observation. Thereafter,\n the pre- existing TPA catheter was removed and sheath was maintained. Through\n this sheath, a 10 mm balloon catheter was inserted. Prior to this\n insertion, 12 ml of intravenous contrast was injected using power injector\n under 3 mL/sec, revealing improvement from the study done one day prior with\n numerous collateral straining into the SVC, though persistent non- filling of\n the left brachiocephalic and medial subclavian vein. Thereafter, the balloon\n was advanced into the region of non-filling, specifically the left\n brachiocephalic and medial subclavian veins and inflated under fluoroscopic\n observation. Following sequential inflations, a second power injection of 12\n ml of contrast was performed and showed improvement with partial filling of\n the left subclavian and brachiocephalic veins as well as extensive\n collateralization, though not complete normalization of venous patency.\n Following this, the balloon catheter, wire and pre-existing introducer\n sheath were all removed and pressure was held at the site of venipuncture\n (Over)\n\n 12:56 PM\n UNILAT SUBCLAV Clip # \n Reason: venogram upper extremity, left, to assess clot burden\n Admitting Diagnosis: LEFT IJ CLOT\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n until local hemostasis was achieved. The site was dressed in a sterile\n fashion using 2 x 2 dressing as well as small Tegaderm patch. The patient\n tolerated the procedure well and without complication and was transferred from\n the angiography suite in stable condition.\n\n IMPRESSION: Partial improvement from study done one day earlier with\n persistent incomplete patency of the left brachiocephalic and medial\n subclavian vein following repeat angioplasty.\n\n We would recommend that the patient remain on anticoagulation (i.e., heparin,\n Lovenox) for extended period of time, at least three to six months. This\n recommendation was made over the telephone by Dr. to Dr. on , at approximately 3:30 p.m.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-06 00:00:00.000", "description": "L VENOUS DUP EXT UNI (MAP/DVT) LEFT", "row_id": 1088649, "text": " 2:07 PM\n VENOUS DUP EXT UNI (MAP/DVT) LEFT Clip # \n Reason: evaluate for DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with L-sided port with neck and LUE swelling\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS STUDY.\n\n HISTORY: Left-sided port with new neck and left arm swelling.\n\n There is acute thrombus involving the left internal jugular vein. Though\n patency of the subclavian, axillary, and brachial veins is identified, there\n is loss of phasicity involving the left subclavian vein which would suggest a\n more central high-grade stenosis or occlusion, such as at the brachiocephalic\n level.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-07 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 1088751, "text": " 3:38 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: Please evaluate for fracture.\n Admitting Diagnosis: LEFT IJ CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with L foot pain.\n REASON FOR THIS EXAMINATION:\n Please evaluate for fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left foot pain, to evaluate for fracture.\n\n FINDINGS: Three views show no evidence of acute fracture or dislocation.\n There is some hypertrophic spurring dorsally consistent with degenerative\n change. Substantial inferior and posterior calcaneal spurs are seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-07 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1088750, "text": " 8:25 AM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: NEW LT IJ CLOT, PLEASE EVAL FOR LT LE DVT\n Admitting Diagnosis: LEFT IJ CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with LIJ DVT with dusky, ? erythematous L leg.\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Recent diagnosis of left internal jugular deep vein\n thrombosis. Dusky left leg.\n\n TECHNIQUE: Grey-scale, color and duplex Doppler imaging of the left lower\n extremity was performed. There are no prior studies for comparison.\n\n FINDINGS: The left common and femoral, greater saphenous, superficial\n femoral, popliteal and posterior tibial veins demonstrate normal flow,\n compressibility and augmentation with no evidence of deep vein thrombosis.\n Plaque is noted along the posterior aspect of the left common femoral artery.\n\n IMPRESSION:\n No evidence of left lower extremity deep vein thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-06 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1088692, "text": " 7:19 PM\n CT CHEST W/CONTRAST Clip # \n Reason: KNOWN IJ CLOT, LT ARM SWEELLING\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with known L IJ clot, L arm swelling\n REASON FOR THIS EXAMINATION:\n eval for SVC clot, SVC syndrome\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy WED 8:34 PM\n no evidence of SVC clot. there is decreased contrast enhancement of the left\n IJ, consistent with known clot. left axillary and left subclavian enhance\n normally. left subclavian line terminates in the SVC. lungs are clear with\n bibasilar atelectasis. heart, aorta and great vessels are unremarkable.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with known left IJ clot and left arm swelling.\n Evaluate for SVC clot/SVC syndrome.\n\n COMPARISON: Venous ultrasound of the upper extremities performed earlier the\n same day revealing left internal jugular clot.\n\n TECHNIQUE: Contrast-enhanced imaging through the chest was performed with\n administration of 90 cc of Visipaque contrast and a 75-second delay.\n Multiplanar reformats were prepared and reviewed.\n\n FINDINGS: There is a left internal jugular central line seen terminating in\n the mid SVC. There is decreased attenuation in the left internal jugular vein,\n proximal to the catheter insertion seen on series 2, image 1, consistent with\n known clot. The SVC is patent with normal opacification. However, There is\n relative hypodensity in the left brachiocephalic vein along the course of the\n catheter. There is also ill-definition of the vein with infiltration of the\n adjacent mediastinal fat, likely dur to edema. Findings are concerning for\n thrombosis of the left brachiocephalic vein around the catheter. The right\n internal jugular, subclavian, and axillary veins appear unremarkable.\n\n The lungs are unremarkable, with no nodule, consolidation, effusion. There is\n minimal bibasilar dependent atelectasis. There is no effusion. There is no\n pneumothorax.\n\n Trace coronary and aortic calcifications noted. The ascending aorta is\n prominent, measuring up to 4.2 cm. There is no aortic dissection. The origins\n of the great vessels are unremarkable. The trachea and central airways are\n patent to the subsegmental level, with no endobronchial lesions. The esophagus\n appears unremarkable. There is no mediastinal, hilar, or axillary adenopathy.\n\n Limited evaluation of the upper abdomen demonstrates multiple peripelvic cysts\n in the left kidney. The right kidney is atrophic, with a small cyst in the\n interpolar region. Visualized portions of the liver and spleen are\n unremarkable. There is a suture line involving the transverse colon. The\n stomach appears unremarkable. A small fluid-filled structure just anterior to\n (Over)\n\n 7:19 PM\n CT CHEST W/CONTRAST Clip # \n Reason: KNOWN IJ CLOT, LT ARM SWEELLING\n Field of view: 40 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the head of the pancreas likely represents a bowel loop, but is incompletely\n visualized (2:74).\n\n IMPRESSION:\n 1. Thrombosis of the left internal jugular vein, left brachiocephalic vein\n (along the catheter), but no evidence of SVC thrombosis.\n 2. Prominence of the ascending aorta measuring up to 4.2 cm.\n 3. Incomplete evaluation of atrophic right kidney, multiple renal cysts, and\n post-surgical changes involving the transverse colon.\n 4. Fluid filled structure adjacent to the pancreatic head may represent a\n small bowel loop, though this region is incompletely imaged (2:74); cannot\n exclude other etiologies for this fluid collection. Recommend clinical\n correlation.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-08 00:00:00.000", "description": "MRI CHEST/MEDIASTINUM W/O & W/CONTRAST", "row_id": 1089080, "text": " 7:39 PM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MRA CHEST W&W/O CONTRASTClip # \n Reason: \\\n Admitting Diagnosis: LEFT IJ CLOT\n Contrast: MAGNEVIST Amt: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with colon Ca and LIJ clot.\n REASON FOR THIS EXAMINATION:\n Please evaluate LIJ for clots/occlusion.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with colon cancer and left IJ clot.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n upper thorax and neck followed by dynamic multiphase gadolinium-enhanced 3D\n T1-weighted gradient echo imaging of the thorax.\n\n FINDINGS: The SVC and right-sided vessels including the brachiocephalic\n veins, internal jugular vein and subclavian veins are widely patent. There is\n complete thrombosis of the visualized internal jugular, subclavian and\n brachiocephalic veins extending to within 1 cm of the brachiocephalic/SVC\n junction. The visualized aorta and great vessels are normal in appearance\n without obvious abnormality. The osseous structures describe a normal marrow\n signal intensity.\n\n IMPRESSION: Occlusion of the left internal jugular, subclavian, and\n brachiocephalic vein extending to within 1 cm of the brachiocephalic/SVC\n junction.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-06 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 1088689, "text": " 6:21 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: ? METS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with colon ca, eval for mets prior to heparinization\n REASON FOR THIS EXAMINATION:\n eval for mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy WED 8:25 PM\n no acute abnormality. no evidence of metastatic disease. no abnormal\n parenchymal, leptomeningeal or dural enchancement. mri is more sensitive for\n detection of small metastases.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with history of colon cancer. Evaluate for\n metastatic disease.\n\n COMPARISON: None available.\n\n TECHNIQUE: Pre- and post-contrast imaging of the brain was performed.\n\n FINDINGS: There is no acute intracranial process, including no hemorrhage,\n edema, or mass effect. There is minimal prominence of the sulci and\n ventricles, consistent with mild parenchymal atrophy. There are no abnormal\n extra-axial fluid collections. There is no shift of midline structures. The\n basilar cisterns are preserved. Following the administration of intravenous\n contrast, there is no abnormal enhancement.\n\n The osseous structures and surrounding soft tissues, including the globes and\n orbits, are unremarkable. The visualized paranasal sinuses and mastoid air\n cells are normally aerated.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. No evidence for metastatic disease. MRI is more sensitive for small\n metastases.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-11 00:00:00.000", "description": "TRANSCATHETER INFUSION FOR LYSIS", "row_id": 1089438, "text": " 2:58 PM\n UNILAT SUBCLAV Clip # \n Reason: Clot lysis\n Admitting Diagnosis: LEFT IJ CLOT\n Contrast: VISAPAQUE Amt: 45\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION FOR LYS 2ND ORDER OR> VENOUS SYSTEM *\n * PTA VENOUS PTA VENOUS *\n * TRANSCATHETER INFUSION EXTREM UNILAT VENOGRAPHY *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with Colon Ca, LIJ and brachiocephalic clot.\n REASON FOR THIS EXAMINATION:\n Clot lysis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old man with recent colon cancer and surgical placement\n of left subclavian Port-A-Cath presenting with left internal jugular,\n brachiocephalic, and subclavian venous clot. Evaluate for the possibility of\n thrombolysis or balloon dilatation.\n\n OPERATORS: Drs. , and , attending. Dr.\n was present and supervising the entire procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n fentanyl and Versed throughout the total intraservice time of 2 hours and 10\n minutes.\n\n PROCEDURE: Prior to the arrival in the angiography suite, written informed\n consent for the procedure was obtained and a preprocedure timeout was\n performed upon arrival using name, date of birth, and medical record number as\n identifiers. Using a micropuncture kit, access was obtained under son\n guidance into the left brachial vein. A hand injected venogram was then\n performed demonstrating complete occlusion of the left subclavian vein along\n nearly its entire course as well as left brachiocephalic vein. Micropuncture\n sheath was then exchanged for a 5 French sheath over a 0.035 Glidewire. This\n Glidewire was passed through the clot/stenosis into the superior vena cava\n into the inferior vena cava. A 5 French C2 Cobra glide catheter was extended\n to the left subclavian vein where left subclavian venogram was performed\n confirming the hand injection findings of near complete occlusion of the left\n subclavian and left brachiocephalic vein. Reconstitution is demonstrated\n within the superior vena cava. The Glidewire was exchanged for wire\n which was secured into the IVC. A 10- mm balloon was then used to\n dilate the entire tract of occlusion extending from the junction of the SVC\n and the left brachiocephalic all the way through the subclavian vein. Minimal\n improvement was demonstrated on a post-balloon dilatation angiogram. Next a\n infusion catheter (5 French) was placed across the clot within the\n subclavian and brachiocephalic vein and initial bolus of TPA was\n administered (5mg). The infusion catheter was left in place in a brachial\n vein to allow for constant infusion overnight. There were no immediate\n (Over)\n\n 2:58 PM\n UNILAT SUBCLAV Clip # \n Reason: Clot lysis\n Admitting Diagnosis: LEFT IJ CLOT\n Contrast: VISAPAQUE Amt: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n complications.\n\n IMPRESSION:\n\n 1. Severe stenosis and thrombotic occlusion in the left brachiocephalic and\n left subclavian vein. Minimal improvement after balloon dilatation with 10 mm\n balloon.\n\n 2. TPA bolus during the procedure with overnight infusion of 0.5 mg per hour\n to follow procedure.\n\n" } ]

[ { "category": "Echo", "chartdate": "2162-09-02 00:00:00.000", "description": "Report", "row_id": 61983, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. s/p femur fracture repair c/b flash pulmonary edema.\nHeight: (in) 71\nWeight (lb): 225\nBSA (m2): 2.22 m2\nBP (mm Hg): 91/51\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 11:29\nTest: 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. No ASD by 2D or color\nDoppler. The IVC was not visualized. The RA pressure could not be estimated.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Low normal LVEF. TDI E/e' < 8, suggesting normal PCWP\n(<12mmHg). No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. Prolonged\n(>250ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\npatient unable to cooperate. Left pleural effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses and cavity size are normal.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). There is hypokinesis of the\nbasal inferolateral wall. Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic root is mildly dilated at the sinus\nlevel. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion. There is an anterior space which most likely represents a prominent\nfat pad.\n\nIMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall\nthickness with low normal global left ventricular systolic function and\nregional wall motion abnormality as described above. Mildly dilated aortic\nroot. Mild aortic regurgitation. Moderate pulmonary artery systolic\nhypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-31 00:00:00.000", "description": "O HIP 1 VIEW IN O.R.", "row_id": 1204125, "text": " 5:43 PM\n HIP 1 VIEW IN O.R. Clip # \n Reason: ORIF LEFT HIP\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n WET READ: DLrc TUE 7:46 PM\n Status post ORIF of the left hip with standard appearance of the hardware and\n no evidence of complication.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Total hip replacement for femoral fracture.\n\n A single intraoperative bedside image of the proximal left hip shows a\n satisfactorily positioned bipolar hemiarthroplasty with cemented femoral stem.\n This has been placed since pre-operative exam showing subcapital fracture done\n earlier same day. Apparently a fracture occurred in the femoral shaft at the\n time of stem placement with a single cerclage wire present. There is a gas in\n the adjacent subcutaneous tissues.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1203552, "text": " 12:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with MS change, on coumadin\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PBec FRI 4:21 PM\n no acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change, on Coumadin.\n\n COMPARISON: Comparison is made to head CT performed .\n\n FINDINGS: There is no evidence of hemorrhage, edema, large masses, mass\n effect or acute infarct. Ventricles and sulci are prominent, consistent with\n age-related parenchymal involution. Vascular calcifications are noted in the\n bilateral carotid siphons and vertebral arteries. No fracture identified.\n The mastoid air cells, middle ear cavities and paranasal sinuses are clear.\n No soft tissue swelling evident.\n\n IMPRESSION: No acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1203539, "text": " 11:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with altered febrile\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Febrile.\n\n COMPARISON: .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Left-sided subclavian central venous\n catheter tip terminates in the SVC. Previously noted right PICC has been\n removed. The heart size remains mildly enlarged. The aorta is tortuous and\n calcified. There is crowding of the bronchovascular structures with low lung\n volumes noted. Patchy opacities in the lung bases are present. There are\n probable trace bilateral pleural effusions. No pneumothorax is identified.\n Thoracic spinal fusion hardware is present.\n\n IMPRESSION: Low lung volumes with patchy opacities in lung bases. Findings\n most likely relate to atelectasis, though infection cannot be excluded.\n Probable small bilateral pleural effusions.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2162-08-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1203567, "text": " 1:46 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: position?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with central line placed\n REASON FOR THIS EXAMINATION:\n position?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with central line placement.\n\n COMPARISON: Chest radiograph from at 11:58.\n\n FINDINGS: In comparison to prior study from 11:58 a.m. on the same date,\n there has been new placement of a right internal jugular central venous line\n with the catheter tip in the superior vena cava. Left subclavian central\n venous catheter is again visualized and the tip terminates in the superior\n cavoatrial junction. Otherwise, there has been no interval change in\n comparison to prior study. The heart size remains mildly enlarged. The aorta\n remains tortuous and calcified. Mild patchy opacities are again visualized at\n bilateral bases. No pneumothorax is identified.\n\n IMPRESSION: New right internal jugular central venous line with the catheter\n tip in the superior vena cava. No pneumothorax. Otherwise, no significant\n interval change in comparison to prior study from 11:58 a.m. on the same day.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2162-08-27 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1203553, "text": " 12:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE? acute abd process?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with MS change, on coumadin with hypoxia and non-focal abd pain\n REASON FOR THIS EXAMINATION:\n PE? acute abd process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PBec FRI 4:59 PM\n 1. no PE.\n 2. small 5 mm in RLL pulm nodule. rec f/u chest CT in 12 mos.\n 3. left femoral neck fx, new since and likely acute given lack of callous\n formation.\n 4. no acute abd process.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with mental status change, on Coumadin with hypoxia, non\n focal abdominal pain, please evaluate for acute abdominal process or PE.\n\n COMPARISON: Comparison is made to CT abdomen and pelvis performed , .\n\n TECHNIQUE: Non-contrast axial images obtained through the chest.\n Subsequently, intravenous contrast was administered and arterial phase imaging\n was performed in the chest. Coronal, sagittal and oblique reformats were\n provided of the chest. Additionally, delayed venous phase imaging was\n performed of the abdomen and pelvis. Coronal and sagittal abdominal\n reformations were provided.\n\n FINDINGS:\n\n CTA CHEST: The pulmonary vasculature is well opacified and there are no\n filling defects to suggest pulmonary emboli. Atherosclerotic calcifications\n are noted in the thoracic aorta without associated aneurysmal change or\n dissection. Coronary artery disease is also identified within the coronary\n arteries. Anterior pericardial calcification are also noted, unchanged\n compared to prior study. Heart size is normal without pericardial effusion.\n\n CT CHEST: The thyroid gland is unremarkable. There is no supraclavicular or\n axillary lymphadenopathy evident. Multiple prominent, though not\n pathologically enlarged lymph nodes are noted within the mediastinum,\n particularly in the prevascular space and aortopulmonary window. Prominent\n lymph nodes are also noted in the right hila. Airways are patent to the\n subsegmental levels. Minimal atelectatic changes are identified in the\n dependent portions of the lungs, right greater than left. A small punctate\n granuloma is identified within the inferior aspect of the right upper lobe\n adjacent to the fissure (2:30). Slightly superior to this in the right upper\n lobe, a ground-glass nodule is identified measuring 5 mm (2:26). No focal\n opacifications concerning for pneumonia are evident.\n (Over)\n\n 12:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE? acute abd process?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT ABDOMEN: The liver is homogenous in attenuation without discrete masses or\n other lesions. Minimal periportal edema is evident, possibly related to\n resuscitative efforts. The gallbladder is unremarkable, though a small amount\n of pericholecystic fluid is seen between the liver and the gallbladder. The\n pancreas is noted to contain multiple rounded hypodensities (3B:106), which\n may represent interdigitating fat. These are stable compared to .\n Spleen is unremarkable. The bilateral adrenal glands have normal limb\n thickness without convex margin to suggest mass. The bilateral kidneys are\n symmetric in size and excrete contrast symmetrically. A 1.9-cm simple cyst is\n noted in the interpolar region of the left kidney. Compared to ,\n there is improved perinephric and periureteral stranding. No hydronephrosis\n or hydroureter evident. The stomach and small bowel are unremarkable.\n Scattered diverticula are present within the large bowel without associated\n inflammation to suggest diverticulitis.\n As before, there are multiple prominent retroperitoneal lymph nodes, none\n of which meet CT criteria for pathological enlargement. No mesenteric or\n portacaval lymphadenopathy evident. No free fluid or air identified in the\n abdomen. The atherosclerotic plaques are noted throughout the abdominal aorta\n without associated aneurysmal change. Plaques are also noted at the ostia of\n the celiac and superior mesenteric artery without evidence of critical\n stenosis. The main portal vein and its major tributaries are unremarkable.\n The bilateral renal veins are widely patent. Atherosclerotic plaques are\n identified at the ostia of the bilateral renal arteries, though flow is noted\n distally.\n\n CT PELVIS: The appendix is visualized and is unremarkable. Linear\n hyperdensities in the rectum may represent a rectal tube. Please correlate\n with clinical history. As before, there is shaggy thickening of the bladder\n wall, though thickening and surrounding fat appears improved compared to\n , changes may relate to neurogenic bladder. No free fluid in the\n pelvis. The pelvic sidewall or inguinal lymphadenopathy identified. Bilateral\n moderate sized fat containing inguinal hernias are present.\n\n OSSEOUS STRUCTURES: Compared to , there has been interval\n development of a left femoral neck fracture, which appears acute as there is\n no bony callus formation to suggest interval healing. Minimal surrounding\n soft tissue inflammation present (500B:39, 3B:163). No suspicious lytic or\n blastic lesions are evident. Multilevel degenerative changes are noted in the\n thoracic and lumbar spine with multiple compression deformities, unchanged,\n and note of bilateral fusion rods spanning prior compression deformities in\n the thoracic spine.\n\n IMPRESSION:\n 1. No pulmonary embolism, aortic dissection or aneurysm is evident.\n (Over)\n\n 12:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: PE? acute abd process?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Scattered diverticula without diverticulitis.\n 3. Thickened and trabeculated urinary bladder, possibly related to neurogenic\n bladder, but correlation with urinalysis recommended to exclude\n cystitis/infection.\n 4. Interval development of a left femoral neck fracture, likely acute.\n 5. Mild periportal edema and pericholecystic fluid may be due to third\n spacing.\n\n" }, { "category": "Radiology", "chartdate": "2162-08-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1204143, "text": " 9:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please rule out pathology, especially right side\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hypoxia s/p OR. Right sided crackles heard on exam.\n REASON FOR THIS EXAMINATION:\n Please rule out pathology, especially right side\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:15 P.M., \n\n HISTORY: Hypoxia. Right-sided crackles.\n\n IMPRESSION: AP chest compared to :\n\n Moderate right pleural effusion obscures much of the right mid and lower lung\n zones. There may also be a large region of upper lobe consolidation. On the\n left pattern is more typical of pulmonary edema. Heart size is large but\n difficult to assess because the margins are indistinct. No pneumothorax.\n\n A left subclavian infusion line passes at least as far as the low SVC, but is\n obscured by spinal hardware. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-08-31 00:00:00.000", "description": "LO FEMUR (AP & LAT) LEFT IN O.R.", "row_id": 1204116, "text": " 4:33 PM\n FEMUR (AP & LAT) LEFT IN O.R. Clip # \n Reason: PRE OP FILMS FEMUR FX\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left femur, two views, .\n\n CLINICAL HISTORY: Patient with femur fracture. Preop radiographs.\n\n FINDINGS: There is generalized demineralization. There is a fracture\n involving the left proximal femur at the femoral head and neck junction. The\n shaft and distal portion of the left femur is grossly intact. There are\n degenerative changes involving the medial compartment of the left knee.\n Degenerative changes of the left hip are also seen with joint space narrowing\n and spurring in the superolateral aspects. Calcification is seen at the\n hamstring attachment to the ischial tuberosities.\n\n" }, { "category": "Radiology", "chartdate": "2162-08-27 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 1203612, "text": " 6:34 PM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: ? effusion, ? fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with left knee pain after surgery\n REASON FOR THIS EXAMINATION:\n ? effusion, ? fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT KNEE, TWO VIEWS, AT 1842 HOURS.\n\n HISTORY: Left knee pain after surgery.\n\n COMPARISON: .\n\n FINDINGS: The bones are diffusely demineralized which reduces the sensitivity\n for detecting subtle nondisplaced fracture. Within that limitation, no\n fracture or dislocation is evident. Mild degenerative change is seen,\n predominantly in the medial and lateral tibiofemoral compartments. However,\n the joint space is relatively well preserved. There is a\n small-to-moderate-sized suprapatellar joint effusion. Extensive vascular\n calcifications are seen.\n\n IMPRESSION: Small-to-moderate joint effusion as above.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-09-02 00:00:00.000", "description": "REPOSITION CATHETER", "row_id": 1204431, "text": " 4:16 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC.\n Admitting Diagnosis: UROSEPSIS\n This is a power pick\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with paraplegia, urosepsis needs IV antibiotics. Poor\n peripheral access, needs PICC.\n REASON FOR THIS EXAMINATION:\n Please place PICC.\n ______________________________________________________________________________\n FINAL REPORT\n REPOSITIONING OF THE PICC LINE\n\n INDICATION: Malpositioned PICC line coiling up superiorly into the IVC.\n\n OPERATORS: Dr. , fellow.\n\n No sedation was administered for this procedure.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the angiographic table. The existing PICC line catheter was\n prepped and draped in usual sterile fashion.\n\n Initial scout images demonstrated PICC line with its distal tip coiling\n superiorly instead of coursing inferiorly in superior vena cava. As the\n catheter was not exposed, there was no need for exchange of the catheter.\n Therefore, a j-shaped wire was placed through the catheter, and the tip of the\n catheter was repositioned into the appropriate position in the distal SVC.\n The guide wire was removed, and both lumens were aspirated and flushed well.\n The post-procedure image demonstrated appropriate positioning of the PICC line\n in the distal SVC.\n\n IMPRESSION: Repositioning of the PICC line. The tip of the PICC line is\n located in the distal SVC.\n\n" }, { "category": "Radiology", "chartdate": "2162-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1204683, "text": " 5:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval for evidence of pneumonia, interval change, proper\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with left femur fracture, s/p MICU stay for flash pulm edema\n and urosepsis; now with + sputum Cx for MRSA.\n REASON FOR THIS EXAMINATION:\n Pls eval for evidence of pneumonia, interval change, proper PICC placement,\n thank you\n ______________________________________________________________________________\n WET READ: SAT 9:19 PM\n Left subclavian central venous catheter and right PICC both end near the\n superior cavoatrial junction . Low lungs volumes. Decreased mild pulmonary\n edema compared to . Minimal bibasilar atelectasis. No consolidation\n concerning for infection. Small bilateral pleural effusions cannot be\n excluded.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with flash pulmonary edema and PICC .\n\n Comparison is made with prior study, .\n\n Right PICC tip and left subclavian catheter tip are in the cavoatrial\n junction. There are persistent low lung volumes. Cardiomegaly is stable.\n Mild pulmonary edema has markedly improved. Bibasilar atelectasis are larger\n on the right side. If any, there are small bilateral pleural effusions.\n Spinal hardware is again noted.\n\n" }, { "category": "Radiology", "chartdate": "2162-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1204200, "text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: resolving pelmoary edema?\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with Pulmonary edema post op yesterday likely ivf now s/p\n diuresis\n REASON FOR THIS EXAMINATION:\n resolving pelmoary edema?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema, reevaluate after diuresis.\n\n COMPARISON: .\n\n FINDINGS: Semi-erect AP view of the chest shows improvement in the pulmonary\n edema. There are persistent small bilateral pleural effusions. Bibasilar\n atelectasis is unchanged. No pneumonthorax. A left subclavian catheter tip\n terminates within the cavoatrial junction. Fusion hardware is again seen.\n\n IMPRESSION: Improvement in pulmonary edema with persistent small bilateral\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2162-09-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1204406, "text": " 2:31 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl power picc 52cm iv \n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 52cm iv \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n COMPARISON: .\n\n FINDINGS: Single AP view of the chest shows a right upper extremity PICC line\n whose wires coiled in the SVC and a tip which terminates within the right IJ\n that is directed cephalad. Withdrawal and repositioning under fluoroscopic\n guidance is recommended. Otherwise, the exam is unchanged. Again seen is\n mild pulmonary edema with small bilateral pleural effusions. Bibasilar\n atelectasis. No pneumothorax. A left subclavian catheter terminates within\n the cavoatrial junction. Fusion hardware is again seen.\n\n IMPRESSION: Poorly positioned right upper extremity PICC. Repositioning is\n recommended.\n\n" }, { "category": "ECG", "chartdate": "2162-09-05 00:00:00.000", "description": "Report", "row_id": 114452, "text": "Sinus rhythm. No significant change comapred to the tracing done on .\n\n" }, { "category": "ECG", "chartdate": "2162-09-02 00:00:00.000", "description": "Report", "row_id": 114453, "text": "Sinus rhythm. Possible left anterior fascicular hemiblock. Non-specific\nanterolateral T wave changes.\n\n" }, { "category": "ECG", "chartdate": "2162-08-27 00:00:00.000", "description": "Report", "row_id": 114454, "text": "Sinus rhythm. The tracing is marred by sixty cycle baseline artifact. Compared\nto the previous tracing of the rate has slowed. The lateral ST-T wave\nchanges persist. Left anterior fascicular block is again recorded. Otherwise,\nno diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2162-08-27 00:00:00.000", "description": "Report", "row_id": 114455, "text": "Sinus tachycardia. Left anterior fascicular block. Lateral ST-T wave changes.\nCompared to the previous tracing of the rate is much faster.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2104-03-25 00:00:00.000", "description": "Report", "row_id": 1508138, "text": "admission note 1630-1900\n\nMr is a 72 year old man who had a R hip replacement revised today. The original R hip replacement was performed in .\n\n**NKDA**\n\nPMH: CEA in , pt has a R sided stroke and minimal use of RUE. He is able to ambulate with the assist of a quad cane.\n\nIn the OR pt received 3200 cc LR, EBL 800, and 700 urine out. Pt was tranfered to the MICU for close monitoring of respiratory and hemodynamic status.\n\nneuro: Pt arouses to verbal stimuli. Moves extremities on the left, not on the right (not a new finding). Patient does not complain of pain at this time.\n\nresp: Currently on face mask at 8 liters, LS clear.\n\ncv: SR in the 70's, no ectopy. MAP 60-65.\n\naccess: 2 piv and L radial aline.\n\ngi/gu: Patnet foley with clear, yellow urine. Positive BS. Diet is ordered as clear liquid--has not had PO's yet.\n\nskin: Incision on R thigh. Hemovac in place.\n\nsocial: Pt lives with his niece; she was updated by the surgeon post-op.\n\nplan: Monitor resp and hemodynamic status. Follow crits throughout the night. (Labs sent at 1715 are pending). When pain develops there is an order to initiate morphine PCA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-03-26 00:00:00.000", "description": "Report", "row_id": 1508139, "text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\nneuro- pt aphasic at baseline, able to communicate by nodding, does answer y/n to q's. l side w/good strength, follows commands. impaired gag noted\n\ncv- a line at times dampened and difficult to draw, other times reads and draws great.. nbp cuff on as well. hr 70's nsr w/o ectopy noted. bp 90-120's sys, stable. mg was 1.5, repleted w/4 gm o/n.\n\nresp- started eve on 8l face mask, would desat to 91% w/it off. switched to 4l nasal cannula. he has been 97-100% since. he has developed congested junky sounding cough over the course of the night, l/s coarse, minimal gag as well. slight coughing noted w/sips of juice. med team made aware and he has been made npo.. to reeval in the am\n\ngi/gu- as above, requesting though juice through night. does admit to having difficulty swallowing at times. uop has been good through night. no maint ivf's.\n\ns/p r hip repair. hemovac in initially putting out good amts, now ~30cc q2 hrs. no ecchymosis to area. hcts have been stable. abductor pillow in place\n\ncont to follow hcts, monitor resp status, follow up w/?swaqllow study vs. trying again w/po's in the am. ?cxr today.\n" }, { "category": "Nursing/other", "chartdate": "2104-03-26 00:00:00.000", "description": "Report", "row_id": 1508140, "text": "NSG 0700-1900\nSee patient transfer note.\n" }, { "category": "Radiology", "chartdate": "2104-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900844, "text": " 7:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Aspiration PNA\n Admitting Diagnosis: FAILED RIGHT TOTAL HIP/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o CVA, s/p hip arthroplasty, now with cough 1 day\n post-op\n REASON FOR THIS EXAMINATION:\n ?Aspiration PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE\n\n INDICATION: 73-year-old man with history of cerebrovascular accident,\n aspiration pneumonia.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed. No previous\n study is available for comparison.\n\n There are faint opacities in both lower lobes consistent with patient's\n history of aspiration pneumonia. The lungs are clear otherwise. The heart\n and mediastinum are within normal limits. There is mild tortuosity of the\n thoracic aorta. There is indentation of the trachea on the right side at\n thoracic inlet, which is probably due to tortuous innominate artery.\n\n IMPRESSION: Probable aspiration pneumonia in both lower lobes.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-03-25 00:00:00.000", "description": "O HIP 1 VIEW IN O.R.", "row_id": 900788, "text": " 3:59 PM\n HIP 1 VIEW IN O.R. Clip # \n Reason: TOTAL HIP REPLACEMENT\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Additional information has been obtained from CareWeb Clinical Lookup since\n the approval of the original report. Reason for exam should also state failed\n right hip arthroplasty for revision.\n\n\n 3:59 PM\n HIP 1 VIEW IN O.R. Clip # \n Reason: TOTAL HIP REPLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right hip.\n\n Right hip portable AP in the OR on .\n\n Findings; compared to , reidentified the right hip bipolar prosthesis.\n In the interval, there is new cement surrounding the femoral stem. There is\n lucency between the cement and bone interface measuring up to 3 mm. Alignment\n is anatomic. No evidence of fracture. Several surgical instruments are\n within the operative bed. There is increased lucency over the right proximal\n hip, likely gas introduced during the surgery.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-03-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 901072, "text": " 2:32 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with rising wbc s/p hip arthroplasty.\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL.\n\n INDICATION: Rising white blood count, status post hip arthroplasty, evaluate\n for possible pneumonitis.\n\n FINDINGS: AP and lateral chest views were obtained with the patient in\n sitting semi-upright position. Comparison is made with a previous portable AP\n chest view of . Mild cardiac enlargement and widened and elongated\n thoracic aorta as before. No pulmonary vascular congestion identified. A few\n patchy mostly basal infiltrates are seen, more on the right than on the left\n and are consistent with aspiration pneumonitis. These changes have not\n undergone any significant alteration during the one-day observation interval.\n The lateral pleural sinuses remain free. The lateral chest view is\n underexposed, but significant pleural effusions accumulating in the posterior\n pleural sinuses can be ruled out. Observed are rib deformities on the right\n base involving 4, 5 and 6 consistent with old rib fractures.\n\n IMPRESSION: No evidence of CHF, but basal infiltrates consistent with\n aspiration pneumonitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-03-27 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 901033, "text": " 10:55 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: eval. post-op. please respect anterolateral hip precautions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p R hemiarthroplasty\n REASON FOR THIS EXAMINATION:\n eval. post-op. please respect anterolateral hip precautions while doing x-ray\n (no hip flexion or abduction with external rotation).\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Right hip.\n\n HISTORY: Revision arthroplasty.\n\n RIGHT HIP: Three views including AP view of the pelvis show revision of right\n bipolar hip prosthesis into a cemented unipolar hemiarthroplasty.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2144-11-27 00:00:00.000", "description": "Report", "row_id": 98011, "text": "PATIENT/TEST INFORMATION:\nIndication: Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 169\nBSA (m2): 1.86 m2\nBP (mm Hg): 141/78\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 09:04\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: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\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: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Mild to moderate\n(+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Moderate to severe (3+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: global and regional biventricular systolic function. Normal Mild\nto moderate aortic regurgitation. Moderate to severe mitral regurgitation.\nMild tricuspid regurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , mitral\nregurgitation is slightly less prominent. Pulmonary pressures are\nsignificantly lower. The other findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2144-12-02 00:00:00.000", "description": "Report", "row_id": 98377, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for Mitral valve repair. Aortic valve disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Prosthetic valve function. Pulmonary hypertension. Right ventricular function. Valvular heart disease.\nHeight: (in) 63\nWeight (lb): 160\nBSA (m2): 1.76 m2\nBP (mm Hg): 134/67\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 14:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\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%). [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.]\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. Moderate (2+)\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild 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\nrhythm appears to be A-V paced. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nPrebypass\n\nThe left atrium is dilated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses are normal. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely\nmore depressed given the severity of valvular regurgitation.] 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. Moderate (2+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. There is no structural\nabnormality seen with the mitral valve. The mitral regurgitation is central\nwith an annulus size of 3.8 cm. Moderate [2+] tricuspid regurgitation is seen.\nThere is no pericardial effusion. Dr. was notified in person of the\nresults on at 1330pm.\n\nPost bypass\n\nPatient is AV paced and receiving an infusion of phenylephrine and\nepinephrine. Biventricular systolic function is unchanged. Annuloplasty ring\nseen in the mitral position. It appears well seated and there is no residual\nmitral regurgitation. Mean gradient across the mitral valve is 4 mm Hg.\nModerate aortic insufficiency persists. There is also moderate tricuspid\nregurgiation. Aorta appears intact post decannulation.\n\n\n" }, { "category": "Echo", "chartdate": "2144-11-30 00:00:00.000", "description": "Report", "row_id": 98378, "text": "PATIENT/TEST INFORMATION:\nIndication: Degree of MR. . Bicycle Stress Assessment.\nHeight: (in) 66\nWeight (lb): 180\nBSA (m2): 1.91 m2\nBP (mm Hg): 122/70\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 14:23\nTest: Stress Echo (Other)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe patient exercised for 8 minutes 26 seconds (peak 60 ) according to an\nupright bicycle protocol reaching a peak heart rate of 80 bpm and a peak blood\npressure of 140/74 mmHg. The test was stopped because of fatigue. This level\nof exercise represents a limited exercise tolerance for age. In response to\nstress, the ECG showed no ST-T wave changes (see exercise report for details).\nThere were normal blood pressure and heart rate responses to stress.\nResting images were acquired at a heart rate of 63 bpm and a blood pressure of\n122/70 mmHg. These demonstrated normal regional and global left ventricular\nsystolic function. Doppler demonstrated mild aortic regurgitation and moderate\nmitral regurgitation with no aortic stenosis or significant resting LVOT\ngradient. The estimated pulmonary artery systolic pressure is normal.\nEcho images were acquired within 60 seconds after peak stress at heart rates\nof 80-70 bpm. These demonstrated appropriate augmentation of all left\nventricular segments. Color Doppler images were obtained in the apical 4 and 2\nchamber 35 seconds post-exercise at a heart rate of 77/min. These demonstrated\nmoderate mitral regurgitation. Peak exercise TR gradient of 59 mmHg suggests\nmoderate pulmonary with exercise.\n\nIMPRESSION: Limited functional exercise capacity. No 2D echocardiographic\nevidence of inducible ischemia to achieved workload. Mild aortic regurgitation\nat rest. Moderate mitral regurgitation at rest and no change with exercise.\nExercise-induced pulmonary is suggested.\n\n\n" }, { "category": "Echo", "chartdate": "2144-11-24 00:00:00.000", "description": "Report", "row_id": 98379, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Mitral valve disease.\nHeight: (in) 66\nWeight (lb): 177\nBSA (m2): 1.90 m2\nBP (mm Hg): 140/72\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 16:18\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: All four pulmonary veins identified and enter the left atrium.\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: Overall normal LVEF (>55%). [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TR present -\ncannot be quantified. Moderate PA systolic .\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. 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.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). (Intrinisic LV function\nmay be depressed given the presence of significant mitral regurgitation).\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened. No masses or vegetations are seen on the\naortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. No mass or vegetation is seen on the mitral\nvalve. There is no frank mitral valve prolapse but there is some leaflet\nredundancy. Moderate to severe (3+) central mitral regurgitation is seen. No\nreversal of flow is identified in the pulmonary veins (4 seen entering the\nleft atrium). There is at least moderate pulmonary artery systolic\n. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2144-11-23 00:00:00.000", "description": "Report", "row_id": 98380, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Congestive heart failure. Left ventricular function.\nHeight: (in) 66\nWeight (lb): 177\nBSA (m2): 1.90 m2\nBP (mm Hg): 122/74\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 10:24\nTest: 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: Mildly dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\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.] No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nSevere PA systolic .\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Echocardiographic\nresults were reviewed by telephone with the houseofficer caring for the\npatient.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n10-20mmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of valvular\nregurgitation.] Right ventricular chamber size is mildly increased with\npreserved free wall motion. The diameters of aorta at the sinus, ascending and\narch levels are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild to moderate (+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Severe (4+) mitral regurgitation is seen. There is severe\npulmonary artery systolic . Significant pulmonic regurgitation is\nseen. There is no pericardial effusion.\n\nIMPRESSION: Mildly thickened mitral valve leaflets with severe mitral\nregurgitation. Severe pulmlonary artery systolic . Right\nventricular cavity enlargement with preserved systolic function. Normal left\nventricular cavity size with preserved regional and global systolic function.\nMild-moderate aortic regurgitation.\nIs the patient a surgical candidate?\n\n\n" }, { "category": "ECG", "chartdate": "2144-11-23 00:00:00.000", "description": "Report", "row_id": 277492, "text": "Atrial paced rhythm. Mild Q-T interval prolongation. Since the previous tracing\nof there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2144-11-18 00:00:00.000", "description": "Report", "row_id": 277493, "text": "Baseline artifact. Probable atrial paced rhythm. ST-T wave abnormalities. Since\nthe previous tracing of ST-T wave abnormalities are more prominent but\nthe QTc interval is shorter.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370289, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n Transfused 1U pRBCs, Hct bumped from 22.6 to 26.9.\n Minimal urine output, increased to 20cc/hr after blood infusion. Giving\n 500cc bolus of D5HCO3\n This morning agitated, screaming, pulling at clothes and lines,\n appeared paranoid. Per husband, has happened previously and responded\n to pain meds.\n Given Haldol 1mg IV, Morphine 2mg IV and benadryl 25mg IV.\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 05:55 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: 36.6\nC (97.9\n HR: 87 (79 - 91) bpm\n BP: 98/77(83) {83/14(46) - 133/87(95)} mmHg\n RR: 13 (8 - 20) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,225 mL\n 640 mL\n PO:\n TF:\n IVF:\n 225 mL\n 290 mL\n Blood products:\n 350 mL\n Total out:\n 200 mL\n 72 mL\n Urine:\n 53 mL\n 72 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,025 mL\n 568 mL\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 67 K/uL\n 7.4 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 5.5\n 4.5\n 4.7\n Hct\n 23.5\n 22.6\n 26.9\n Plt\n 68\n 68\n 67\n Cr\n 2.3\n 1.9\n 1.7\n Glucose\n 111\n 89\n 103\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL.\n Retic 0.5, Fibrinogen 373, Iron 39, TIBC 164, Folate, Ferritin, B12 >\n assay, TSH 3.1\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Likely hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure, worsening LFT\n abnormalities and narcotics in setting of poor substrate and poor\n reserve leading to deficits as noted and exacerbation of old CVA\n deficits.\n Other likely contributors contributors:\n - toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure and worsening LFTs)\n - left lower lobe infiltrate, likely aspiration\n Les likely contributors:\n - CVA or TIA, (CT head prelim neg)\n - infection of indwelling port, urine (UA bland), CNS (no consistent\n symptoms)\n - seizures with post-ictal state in setting of brain metastases\n - intracranial hemorrhage/mass effect/edema (no evidence on CT scan)\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed.\n - Will continue to monitor and unless starts to bleed\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370353, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n Patient was agitated most of the night with periods of quiet time in\n between,oriented to self pulling at clothes and lines,speech is not\n clear,c/o pain on lower limbs continued to have low grade temps HR 150\n when pt was agitated Appears to be delirious and paranoid, Head CT\n from EW\n no acute bleed or stroke.\n Action:\n Continue lactulose for question of hepatic encephalopathy ( however at\n this time unable to give PO\ns poor mental status)NS 500 ml bloused\n and Metoprolol 5 mg/IV and Haldol 1 mg/Iv,Benadryl IV,Morphine IV given\n with effect.\n Response:\n Patient appears to be calm later, comfortable, follows commands.\n Plan:\n Pt is DNR/DNI Continue to monitor patient\ns mental status, f/u Cx data\n and electrolytes, IVF hydration\n" }, { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370282, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n Transfused 1U pRBCs, Hct bumped from 22.6 to 26.9.\n Minimal urine output, increased to 20cc/hr after blood infusion. Giving\n 500cc bolus of D5HCO3\n This morning agitated, screaming, pulling at clothes and lines,\n appeared paranoid. Per husband, has happened previously and responded\n to pain meds.\n Given Haldol 1mg IV, Morphine 2mg IV and benadryl 25mg IV.\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 05:55 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: 36.6\nC (97.9\n HR: 87 (79 - 91) bpm\n BP: 98/77(83) {83/14(46) - 133/87(95)} mmHg\n RR: 13 (8 - 20) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,225 mL\n 640 mL\n PO:\n TF:\n IVF:\n 225 mL\n 290 mL\n Blood products:\n 350 mL\n Total out:\n 200 mL\n 72 mL\n Urine:\n 53 mL\n 72 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,025 mL\n 568 mL\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 67 K/uL\n 7.4 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 5.5\n 4.5\n 4.7\n Hct\n 23.5\n 22.6\n 26.9\n Plt\n 68\n 68\n 67\n Cr\n 2.3\n 1.9\n 1.7\n Glucose\n 111\n 89\n 103\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL.\n Retic 0.5, Fibrinogen 373, Iron 39, TIBC 164, Folate, Ferritin, B12 >\n assay, TSH 3.1\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Likely hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure, worsening LFT\n abnormalities and narcotics in setting of poor substrate and poor\n reserve leading to deficits as noted and exacerbation of old CVA\n deficits.\n Other likely contributors contributors:\n - toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure and worsening LFTs)\n - left lower lobe infiltrate, likely aspiration\n Les likely contributors:\n - CVA or TIA, (CT head prelim neg)\n - infection of indwelling port, urine (UA bland), CNS (no consistent\n symptoms)\n - seizures with post-ictal state in setting of brain metastases\n - intracranial hemorrhage/mass effect/edema (no evidence on CT scan)\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370287, "text": "Chief Complaint: Altered mental status\n HPI:\n Ms. is a 74 year old female with widely metastatic breast\n cancer (metastases to brain, lung, bone, and liver), on coumadin for\n DVT, history of a with right sided deficit, who presented with an acute\n change in mental status, weakness, and word garbling per her husband\n now with AMS, word garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n .\n Yesterday, she went for an INR check and felt lethargic and weak. Her\n weakness was more notable on her left side, which is usually her\n stronger side. She was unable to get out of the car without significant\n assistance. She was noted to be slurring her speech, but otherwise was\n making sense. At the clinic, the nursing team had a difficult time\n obtaining blood. She then reported she wanted to go home and go to bed.\n She then went to bed, and per her husband, awoke later than usual in\n the morning, around 10 AM. He noticed at that time her face was\n asymetric, especially her mouth. She again had difficulty speaking and\n it was apparently difficult to get the words out. She did not want\n breakfast, and her husband fed her breakfast. At this time, her husband\n was concerned and brought her in for evaluation. He states she has not\n urinated since yesterday. There had been no changes in her urine noted.\n She has poor PO intake, usually only eating breakfast, with poor fluid\n intake. She was also recently started on Megace, which was stopped\n about one week ago due to an elevated INR.\n .\n In the emergency department, her initial vital signs were: temperature\n of 98.1, blood pressure of 102/80, heart rate of 86, respiratory rate\n of 16, and oxygen saturation of 98% on room air. While in the\n emergency room, her blood pressure flucuated from 67 systolic to 93\n systolic. She received a total of three liters of IVF for intermittent\n hypotension, with fair response. She was given 2 grams of ceftriaxone,\n 1 gram of vancomycin, 2 grams of ampicillin, 25 mg of benadryl, and\n percocet 5/325 mg times two.\n .\n She was noted to have a right-sided facial droop, which per report was\n old. She was guaiac negative. A head CT was without a bleed or edema.\n Her laboratories were remarkable for thrombocytopenia, anemia, and new\n renal failure. An urinanalysis was unremarkable. She was started on\n empiric antibiotic coverage for bacterial meningitis emergency room\n physician discussed her case with on-call hematology/oncology fellow. A\n lumbar puncture was not pursued as her INR was 4.2, and it was felt\n this was no consistent with her goals of care.\n .\n While she was in the emergency room, her mental status may have\n improved somewhat, but she is not back to her baseline. Upon sign-out\n to ICU team, ampicillin for listeria coverage was discussed and given\n prior to leaving the ED.\n .\n Of note, her last gemcitabine therapy was on , with neupogen\n given on and . Per report from her husband, this therapy is no\n longer working, and a different therapy plan will be pursued in the\n coming weeks after a break from any therapies.\n .\n Upon arrival to the ICU, patient's blood pressure was 102/46. She\n denied any discomfort and would answer some questions appropriately.\n Home medications:\n 1. Atorvastatin 20 mg PO DAILY\n 2. Carvedilol 3.125 mg PO DAILY\n 3. Folic Acid 1 mg PO DAILY\n 4. Furosemide 20 mg PO EVERY OTHER DAY\n 5. Lisinopril 5 mg PO DAILY\n 6. Zolpidem 5 mg PO HS prn\n 7. Aspirin 81 mg PO DAILY\n 8. Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn\n 9. Coumadin 5 mg PO once a day\n 10. Oxycodone 20mg SR qhs prn\n 11. Lactulose 30ml prn\n 12. Oxycodone-Acetaminophen 5 mg-325 mg 1-2t PO q4 prn\n ALLERGIES: Patient previously reported an allergy to shellfish and\n iodinated contrast, however per OMR, she has confirmed since then,\n along with her husband, that she is not allergic and can tolerate CTs\n with contrast\n Past medical history:\n Oncologic History:\n - Diagnosed with breast cancer in , initially diagnosed as\n inflammatory breast cancer\n - ER positive\n - Received neoadjuvant doxorubicin and taxotere, followed by\n right mastectomy and radiation\n - Initially on Tamoxifen x 2 years (started )\n - developed sclerotic lesion of right proximal humerus;\n treated with XRT and switched from Tamoxifen to Arimidex\n - : Bone scan revealed extensive areas of increased\n uptake, likely bony metastases\n - started Clinical Trial 03-410, estradiol followed by\n fulvestrant in postmenopausal women with ER positive metastatic\n breast cancer\n - : CT torso indicated increased metastases, with\n pulmonary nodules, liver lesions, and diffuse bony involvement\n - : Taxol/Avastin, then single Taxol\n - : Started on Xeloda\n - / CMF (cyclophosphamide, methotrexate, 5-FU)\n - Received whole brain radiation in for known CNS\n metastases\n - / Navelbine\n - / 11 cycles of Doxil\n - - gemcitabine x 5 cycles\n - started XRT for two posterior fossa metastases\n .\n Past Medical History:\n 1. Cardiomyopathy secondary to Adriamycin. Most recent echo \n shows mild regional left ventricular systolic dysfunction. No\n pathologic valvular abnormality or significant outflow tract\n gradient seen. Mild pulmonary artery systolic hypertension, LVEF\n probably similar to previous (50%). Followed by Dr. .\n 2. Osteoarthritis, s/p 2 knee replacements, and another in \n 3. Lymphedema\n 4. CVA with right hemiparesis, 12/. Followed by Dr. .\n 5. DVT on coumadin therapy\n Family history:\n The patient's father died of rectal cancer.\n Social History:\n Patient does not smoke tobacco or use illicit drugs. Per OMR notes, she\n drinks a glass of wine a few times a week. She lives with her husband,\n and mainly bed-bound.\n Review of systems:\n Review of systems is otherwise negative for fevers, recent illness,\n chills, nightsweats, nausea, vomiting, diarrhea, constipation, chest\n pain, shortness of breath. No neck stiffness, headache, visual\n symptoms.\n Flowsheet Data as of 10:23 PM\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: 86 (86 - 91) bpm\n BP: 83/35(48) {83/14(47) - 133/87(95)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,029 mL\n PO:\n TF:\n IVF:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 180 mL\n Urine:\n 33 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,849 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 28 mg/dL\n 18 mEq/L\n 113 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 22.6 %\n 4.5 K/uL\n [image002.jpg]\n \n 2:33 A3/28/ 08:16 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 4.5\n Hct\n 22.6\n Plt\n 68\n Cr\n 1.9\n Glucose\n 89\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n IMAGING:\n Chest x-ray\n 1. Left lower lobe opacity may represent pneumonia or edema. Recommend\n repeat\n imaging after diuresis to excluded underlying infection.\n 2. Minimal CHF.\n 3. Moderate left and small right pleural effusion.\n .\n EKG: Sinus, LBBB, normal axis, LVH, TW flattening in II, III, aVF and\n aVL.\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Differential includes CVA or TIA,\n toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure) or infection (potential sources include lung with\n possible aspiration given decreased mental status over last few days,\n indwelling port, urinary infection, CNS though story is less convincing\n for this), seizures with post-ictal state in setting of brain\n metastases, intracranial hemorrhage. Suspect that some degree is likely\n from poor perfusion in setting of hypovolemia and hypotension. Recent\n use of oxycodone could also be contributing to depressed mental status.\n To pull together the story, suspect this is a case of hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure and narcotics in\n setting of poor substrate and poor reserve leading to deficits as noted\n and exacerbation of old CVA deficits.\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine), likely\n treat for aspiration pneumonia given left atelectasis versus\n consolidation\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes\n - Renal failure management as discussed below\n - Consider neurology consult in AM if mental status not improved with\n above interventions, would also consider additional imaging such as MRI\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Minimize narcotics as possible\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility. In setting of thromcytopenia, anemia, and altered mental\n status, TTP/HUS is also a possibility, but no schistocytes or rise in\n T. Bili. She has no known metastates in the pelvis that would account\n for obstruction.\n - Urine electrolytes being sent\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - Repeat peripheral smear in AM to again check for schistocytes\n - Checking urine eosinophils\n - Currently making fairly good urine, will continue to monitor output\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy.\n - Continue IVF boluses as needed for low urine output or systolic <85,\n or if symptomatic, however will use D5 with three amps of bicarb given\n metabolic acidosis (likely secondary to renal failure), and will need\n to be mindful of her cardiomyopathy.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelet could of 68 on presentation. She is day\n 18 of her gemcitabine therapy, so this could represent marrow\n suppression from that cycle (WBC could be disporportionally up\n secondary to administration of GSC-F). Baseline prior to this appears\n to vary, likely secondary to cycles of chemotherapy (75-400's). TTP/HUS\n is consideration as noted above, but no schistocytes, T. Bili is\n normal, no fevers.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED). Will also rule out hemolysis by checking laboratories, however\n no schistocytes on smear noted.\n - Hemolysis labs, reticulocyte count\n - Type and cross, repeat HCT now and likely transfuse two units of\n PRBCs\n - Checking B12, folate, iron (MCV is 109), as suspect poor nutrition\n intake of these\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Differential includes\n secondary to uremia from renal dysfunction, medication effect (pruritis\n started around same time as she started oxycodone, and reported\n incidence of pruritis is up to 12-13%), worsening liver disease (she\n has known metastases).\n - Checking LFT's, renal failure management as noted above\n - Checking TSH, ferritin\n - Sarna PRN, holding off on benadryl or atarax as these may cloud\n assessment of mental status\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. Bilateral leg pain: Unclear etiology. Patient currently unable to\n give further details. In setting of possible urinary retention, cauda\n equina syndrome is a consideration, but patient currently without\n sensory deficits with normal rectal tone and discomfort with rectal\n thermometer. Response to oxycodone also is less consistent with cord\n compression. She has known bony metastases of her pelvis and spine, so\n these could also be causing pain (eg via nerve impingement or\n pathologic fracture)\n - Start with plain films to rule out compression fracture and/or\n pelvis/hip fracture\n - Consider further imaging of spine in AM if/once patient is more\n stable\n - Should she develop new deficits, would consider initiation of\n steroids for question of cord compression\n - Continue oxycodone for pain control\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left leg\n Stress ulcer: PPI\n VAP: N/A\n Comments: N/A\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition: level of care for now until further hemodynamically\n stable.\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370295, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n" }, { "category": "General", "chartdate": "2145-03-22 00:00:00.000", "description": "Speech & Swallow Evaluation", "row_id": 370383, "text": "TITLE: Bedside Swallowing Evaluation\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\n74 year old woman admitted to on with change in\nmental status. She has metastatic breast cancer (liver, lung,\n, ), and has had poor PO intake with a 20# weight loss\nover the past few months. Megace was started but was stopped due\nto negative interaction with other important medications.\nAccording to her nurse, her mental status waxes and wanes from\ncooperative to agitated. She also said that there was a question\nof pneumonia on her CXR in the LLL, and she was noted to have\nthroat clearing and delayed coughing after drinking thin liquids.\nTherefore, she was made NPO and meds were switched to IV and we\nwere consulted to evaluate her oral and pharyngeal swallowing\nability to r/o aspiration to find the safest PO diet with the\nleast aspiration risk.\nPast Medical History:\n1. Cardiomyopathy Adriamycin. Most recent echo shows\nmild regional left ventricular systolic dysfunction. No\npathologic valvular abnormality or significant outflow tract\ngradient seen. Mild pulmonary artery systolic hypertension, LVEF\nprobably similar to previous (50%).\n2. OA s/p 2 knee replacements, and another in \n3. Lymphedema\n4. CVA with right hemiparesis, 12/. Followed by Dr. .\nSocial History:\nNo tobacco or illicit drug use. Drinks a glass of wine a few\ntimes a week. Lives with her husband and has visiting PT.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on 4I.\nCognition, language, speech, voice:\nSpeech was within functional limits. Some paraphasic errors\nheard with nouns in her fluent speech. Voice was slightly\nhoarse. She was oriented to self only.\nTeeth: Full set in poor condition\nSecretions: Dry oral cavity\nORAL MOTOR EXAM:\nLips with Right droop but adequate labial seal\nTongue midline with functional strength\nPalatal elevation was symmetrical. No gag\nSWALLOWING ASSESSMENT:\nPO assessment was conducted with ice chips, water & nectar thick\nliquids via tsp, cup and straw sips, bites of applesauce, one\nbite of cracker and some ground crackers mixed in\napplesauce. Swallows were slightly delayed. Laryngeal elevation\nfelt adequate to palpation. There was throat clearing after one\ntsp of applesauce and after one cup sip of nectar-thick liquid.\nThere was drop in O2 saturation after many of the sips of thin\nliquid which may indicate aspiration with water. O2 sats were\nmore stable after nectar thick liquid & after pureed or solid\nconsistencies.\nSUMMARY / IMPRESSION:\n had \"soft\" signs of aspiration more consistently\nwith thin liquids than with nectar thick liquids, pureed foods or\nsolids. She was in pain and was not able to focus on taking PO's\nthis morning which will contribute to her poor overall PO intake.\nBased on this evaluation, she appears safest on a ground diet\nwith nectar thick liquids and pills whole in puree. I would\nsuggest a nutrition consult and Ensure pudding supplements\nbetween meals. If her mental status and pain improve, we would\nbe happy to repeat the bedside swallowing evaluation to see if\nher diet can be safely upgraded.\nThis swallowing pattern correlates to a Dysphagia Outcome\nSeverity Scale (DOSS) rating of level 5, mild dysphagia.\nRECOMMENDATIONS:\n1. Recommend a ground diet with nectar thick liquids\n2. Pills whole (or crushed) in puree, as appropriate.\n3. I would suggest a nutrition consult and Ensure pudding\n supplements between meals.\n4. If her mental status and pain improve, we would be happy to\n repeat the bedside swallowing evaluation to see if her diet\n can be safely upgraded.\n5. If there are further concerns about aspiration on this diet,\n we would be happy to perform a videoswallow.\n6. If her status changes to Palliative/comfort care; it would be\n fine to liberalize her diet to include thin liquids or soft\n solids.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager # \nFace time: 9:45-10:30 AM\nTotal time: 60 minutes\n 10:34\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 370389, "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 Experienced tachycardia (ST) responded to iv beta-blocker.\n Recurrence this AM wth resolution following beta-blocker.\n Mental status reveals some disorientation and confusion.\n EKG - At 04:08 PM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 11:23 PM\n Metoprolol - 07:15 AM\n Famotidine (Pepcid) - 07:40 AM\n Morphine Sulfate - 10:25 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, 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 Pain: No pain / appears comfortable\n Flowsheet Data as of 01:04 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 90 (90 - 163) bpm\n BP: 114/37(58) {101/37(49) - 147/93(102)} mmHg\n RR: 11 (10 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 1,020 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 1,020 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 897 mL\n Urine:\n 942 mL\n 897 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n 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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Emotionally volatile; teary, weepy\n Labs / Radiology\n 10.8 g/dL\n 106 K/uL\n 77 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.0 %\n 5.8 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n WBC\n 4.5\n 4.7\n 5.8\n Hct\n 22.6\n 26.9\n 32.0\n Plt\n 68\n 67\n 106\n Cr\n 1.9\n 1.7\n 0.8\n Glucose\n 89\n 103\n 77\n Other labs: PT / PTT / INR:19.6/29.3/1.8, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n Altered mental status, delerium, confusion.\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK) -- improved. Monitor.\n ALTERED MENTAL STATUS, DELIRIUM -- Subactue onset. Concerns include\n toxic/metabolic response to pneumonia (LLL). COntribution by\n hypocalcemia. Other concerns include CNS infection (meningitis,\n abscess), leptomeningeal involvement of tumor, increased/progerssion of\n CNS tumor, encephalitis, medication effect. MRI declined by patient\n and husband. LP to assess for infection or malignancy. Correct\n metabolic derrangements.\n HYPOCALCEMIA -- mild. Check ionized. Replete.\n PRURITIS -- symptomatic treatment. Trial prn atarax.\n AGGITATION -- possible related to underlying process.\n RENAL FAILURE -- acute, resolving with iv fluids. Monitor.\n MALIGNANCY -- extensive, widely metastatic.\n Possible INFECTION -- indwelling iv catheter --> line related\n infection. Empirical antimicrobials.\n h/o DVT -- monitor PT on coumadin. Hold coumadin while considering LP.\n NUTRITIONAL SUPPORT -- npo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370392, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Pt tachy to 120s throughout day. Pt recieving 1u PRBC at the time,\n but was still tachy in 100s a couple hrs prior to getting blood. Pt\n denied pain, anxiety, no fevers, normal TSH, and only slightly dry MM -\n but good UOP and +balance nearly 2L - so did not give further fluids at\n the time (and was already getting blood). Came down on its own by 7pm\n - At 11:30pm pt became tachy to 150s - ?SVT. Pt agitated would not\n allow carotid massage, gave metop 5 IV x1, 500ml NS bolus, haldol 1mg\n x1, and pt 's HR returned to 90s.\n EKG - At 04:08 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:39 PM\n Morphine Sulfate - 06:46 PM\n Metoprolol - 11:23 PM\n Haloperidol (Haldol) - 11:23 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 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 139 (96 - 139) bpm\n BP: 147/83(96) {87/40(31) - 147/107(102)} mmHg\n RR: 16 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 815 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 815 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 550 mL\n Urine:\n 942 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\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 67 K/uL\n 9.2 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n WBC\n 4.5\n 4.7\n Hct\n 22.6\n 26.9\n Plt\n 68\n 67\n Cr\n 1.9\n 1.7\n Glucose\n 89\n 103\n Other labs: PT / PTT / INR:47.3/34.7/5.3, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Likely hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure, worsening LFT\n abnormalities and narcotics in setting of poor substrate and poor\n reserve leading to deficits as noted and exacerbation of old CVA\n deficits.\n Other likely contributors contributors:\n - toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure and worsening LFTs)\n - left lower lobe infiltrate, likely aspiration\n Les likely contributors:\n - CVA or TIA, (CT head prelim neg)\n - infection of indwelling port, urine (UA bland), CNS (no consistent\n symptoms)\n - seizures with post-ictal state in setting of brain metastases\n - intracranial hemorrhage/mass effect/edema (no evidence on CT scan)\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed.\n - Will continue to monitor and unless starts to bleed\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with oxycodone, tylenol\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370454, "text": "TITLE:\n Chief Complaint:\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n -RUQ u/s done- no read yet\n -Awaiting Dr to come see pt. If does need an LP would need to be\n done by neurosurg\n -Calcium repleated and free Ca was 1.15\n -Pt required Haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone 1g IV q24\n Vancomycin 1mg IV q48\n Infusions:\n Other ICU medications:\n Simvastatin 40 daily\n Folic acid\n Thiamine\n Senna\n Lactulose 30 \n Famotidine\n Haldol Prn\n Ibuprofen\n Tylenol\n hydroxyzine\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 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 77 (76 - 163) bpm\n BP: 130/35(56) {94/27(47) - 145/102(111)} mmHg\n RR: 13 (10 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,485 mL\n 67 mL\n PO:\n TF:\n IVF:\n 1,485 mL\n 67 mL\n Blood products:\n Total out:\n 1,353 mL\n 170 mL\n Urine:\n 1,353 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 132 mL\n -103 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///25/\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 130 K/uL\n 9.6 g/dL\n 85 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 116 mEq/L\n 147 mEq/L\n 28.8 %\n 4.2 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n 04:06 AM\n WBC\n 4.5\n 4.7\n 5.8\n 4.2\n Hct\n 22.6\n 26.9\n 32.0\n 28.8\n Plt\n 68\n 67\n 106\n 130\n Cr\n 1.9\n 1.7\n 0.8\n 0.6\n Glucose\n 89\n 103\n 77\n 85\n Other labs: PT / PTT / INR:15.8/27.3/1.4, ALT / AST:32/58, Alk Phos / T\n Bili:103/0.9, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.2 g/dL, LDH:411 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Ddx includes infection (likely\n LLL infiltrate), hypocalcemia, leptomeningeal spread of breast CA,\n hypoperfusion, toxic/metabolic encephalopathy (pt was in renal\n failure), narcotics, seizure secondary to brain mets. Could be\n contributing to exacerbation of old CVA deficits.\n -CT of the head negtive for CVA or TIA, bleed, or new edema. Pt still\n has innumerable calcified metastatic foci and mild edema.\n Plan:\n -Hypocalcemia: repleated Ca2+\n - Will discuss with Dr. the possibility of leptomeningeal dz and\n whether LP and cytology would help. Unable to get MRI given pt has\n severe clostrophobia. Holding ibuprofen and coumadin given possibility\n of LP.\n -Bacterial meningitis in ddx but no meningeal sign/fever: pt already on\n ceftriaxone and vancomycin for PNA. If concern for meningitis\n increases would start ampicillin.\n -Infection: LLL infiltrate likely. Continue ceftriaxone and vanco.\n f/u blood cx still pending, urine cx negative\n -Goal MAP >55-60\n - Continue lactulose for question of hepatic encephalopathy\n -Haldol prn for agitation\n -Avoid narcotics and benadryl as much as possible\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal\n (fena 0.1%) in setting of poor PO intake reported by family and\n continuation of home BP medications (ACE-I, lasix, and Coreg). Her\n baseline creatinine is 0.5. Trend of creatinine 2.3 -> 1.9 -> 1.7 ->\n 0.8.\n -continue to trend creatinine\n .\n #PNA: continue cetriaxone and vancomycin.\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. Today pt normotensive (required fluid bolus earlier in\n admission).\n .\n #Increased LFTs\n -RUQ u/s today\n -follow LFTs\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 19 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: HCT since in 29-33 range. On presentation HCT was\n 23.5 and now is 32. Suspect large part of this may be marrow\n suppression secondary to chemotherapy, as has no signs of bleeding\n (guaiac negative in ED). s/p transfusion of 1U with appropriate bump.\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n -.\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and atorax prn.\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with low doses of tylenol or ibuprofen.\n .\n #SVT:\n -metoprolol 5mg IV Prn for HR >120\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n .\n #. History of DVT: Patient's INR was supratherapeutic and now\n subtherapeutic. No current signs of bleeding or history of bleeding.\n - Holding coumadin given possibility of LP, type and cross sent in\n event she needs to be urgently reversed.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with low doses of tylenol (given LFTs) and low doses\n ibuprofen (given kidney fx).\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370446, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n Overnight Ms. was pleasantly confused however she continued\n to refuse all nursing care (meds turning etc.) her vitals remained\n stable and had no further bouts of SVT.\n Altered mental status (not Delirium)\n Assessment:\n Oriented only to person, appeared @ times to be experiencing auditory\n or visual hallucinations as pt was noted to be speaking to\n people/things which were not in the room, no evidence of discomfort,\n rested comfortably throughout shift.\n Action:\n Attempted to administer PO meds and q 2 hr turns\n Response:\n Pt calmly refused all care however did allow morning lab draws\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, probable call out to floor.\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370439, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented with altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed\ninmuerable\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 370416, "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 Experienced tachycardia (ST) responded to iv beta-blocker.\n Recurrence this AM wth resolution following beta-blocker.\n Mental status reveals some disorientation and confusion.\n EKG - At 04:08 PM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 11:23 PM\n Metoprolol - 07:15 AM\n Famotidine (Pepcid) - 07:40 AM\n Morphine Sulfate - 10:25 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, 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 Pain: No pain / appears comfortable\n Flowsheet Data as of 01:04 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 90 (90 - 163) bpm\n BP: 114/37(58) {101/37(49) - 147/93(102)} mmHg\n RR: 11 (10 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 1,020 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 1,020 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 897 mL\n Urine:\n 942 mL\n 897 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n 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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Emotionally volatile; teary, weepy\n Labs / Radiology\n 10.8 g/dL\n 106 K/uL\n 77 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32.0 %\n 5.8 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n WBC\n 4.5\n 4.7\n 5.8\n Hct\n 22.6\n 26.9\n 32.0\n Plt\n 68\n 67\n 106\n Cr\n 1.9\n 1.7\n 0.8\n Glucose\n 89\n 103\n 77\n Other labs: PT / PTT / INR:19.6/29.3/1.8, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n Altered mental status, delerium, confusion.\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK) -- improved. Monitor.\n ALTERED MENTAL STATUS, DELIRIUM -- Subactue onset. Concerns include\n toxic/metabolic response to pneumonia (LLL). COntribution by\n hypocalcemia. Other concerns include CNS infection (meningitis,\n abscess), leptomeningeal involvement of tumor, increased/progerssion of\n CNS tumor, encephalitis, medication effect. MRI declined by patient\n and husband. LP to assess for infection or malignancy. Correct\n metabolic derrangements.\n HYPOCALCEMIA -- mild. Check ionized. Replete.\n PRURITIS -- symptomatic treatment. Trial prn atarax.\n AGGITATION -- possible related to underlying process.\n RENAL FAILURE -- acute, resolving with iv fluids. Monitor.\n MALIGNANCY -- extensive, widely metastatic.\n Possible INFECTION -- indwelling iv catheter --> line related\n infection. Empirical antimicrobials.\n h/o DVT -- monitor PT on coumadin. Hold coumadin while considering LP.\n NUTRITIONAL SUPPORT -- npo\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\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: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370436, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented with altered\n mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370437, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented with altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed\ninmuerable\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370442, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n Overnight Ms. was pleasantly confused however she continued\n to refuse all nursing care (meds turning etc.) her vitals remained\n stable and had no further bouts of SVT.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370409, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing.\n Cardio: B/P 110-130\ns (baseline 80-90\ns) HR at 80\n-100\ns SR/ST while\n agitated up to 130\n 150\ns SVT. RT leg edema. Pulses present. This am\n Hr up to 160\ns SVT/ST. ECG done. Lopressor 5mg given w/positive effect\n (down to 80\n GI: abd soft non tender, positive for BS. No BM this shift. Senna added\n to bowel regimen. NPO for now poor MS. S&S eval\n mild dysphasia\nground diet w/nectar thick liquids until MS improves.\n GU: amber color urine via Foley about 30-40cc/hr\n Skin: multiple ecchymotic areas. C/o itching\n lotion applied and\n benadryl given w/positive effect. Benadryl switched to atarax to\n prevent over sedation.\n IV access: LT chest porthacath\n this am does not draw or flush easily.\n IV nurse re-accessed and redressed the cath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370410, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing.\n Cardio: B/P 110-130\ns (baseline 80-90\ns) HR at 80\n-100\ns SR/ST while\n agitated up to 130\n 150\ns SVT. RT leg edema. Pulses present. This am\n Hr up to 160\ns SVT/ST. ECG done. Lopressor 5mg given w/positive effect\n (down to 80\n GI: abd soft non tender, positive for BS. No BM this shift. Senna added\n to bowel regimen. NPO for now poor MS. S&S eval\n mild dysphasia\nground diet w/nectar thick liquids until MS improves. RUQ US done\n GU: amber color urine via Foley about 30-40cc/hr\n Skin: multiple ecchymotic areas. C/o itching\n lotion applied and\n benadryl given w/positive effect. Benadryl switched to atarax to\n prevent over sedation.\n IV access: LT chest porthacath\n this am does not draw or flush easily.\n IV nurse re-accessed and redressed the cath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370411, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI. c/o LT hip\n pain however confusion unable to grade it on pain scale except\n crying\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing.\n Cardio: B/P 110-130\ns (baseline 80-90\ns) HR at 80\n-100\ns SR/ST while\n agitated up to 130\n 150\ns SVT. RT leg edema. Pulses present. This am\n Hr up to 160\ns SVT/ST. ECG done. Lopressor 5mg given w/positive effect\n (down to 80\n GI: abd soft non tender, positive for BS. No BM this shift. Senna added\n to bowel regimen. NPO for now poor MS. S&S eval\n mild dysphasia\nground diet w/nectar thick liquids until MS improves. RUQ US done\n GU: amber color urine via Foley about 30-40cc/hr\n Skin: multiple ecchymotic areas. C/o itching\n lotion applied and\n benadryl given w/positive effect. Benadryl switched to atarax to\n prevent over sedation.\n IV access: LT chest porthacath\n this am does not draw or flush easily.\n IV nurse re-accessed and redressed the cath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370499, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n EVENTS: MS has cleared to baseline\n Altered mental status (not Delirium)\n Assessment:\n Pt OX3. Does not recall events of previous 48 hrs. No movement of RUE,\n RLE, L side facial, upper body twitch HX previous stroke. Able to\n drink liquids, swallow pills without any choking. ? eti infection,\n meds (on narcs at home), SZ\n Action:\n Ongoing assessment\n Response:\n Remains oriented. No evidence of aspiration\n Plan:\n Cont to assess. Orient PRN\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Taking Po\ns. UO 15-25 cc hr. , Na 147\n Action:\n Encouraging increased PO\n Response:\n Remains oliguric\n Plan:\n Follow Uo, BUN,creat. Follow Na\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370500, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n EVENTS: MS has cleared to baseline\n Altered mental status (not Delirium)\n Assessment:\n Pt OX3. Does not recall events of previous 48 hrs. No movement of RUE,\n RLE, L side facial, upper body twitch HX previous stroke. Able to\n drink liquids, swallow pills without any choking. ? eti infection,\n meds (on narcs at home), SZ\n Action:\n Ongoing assessment\n Response:\n Remains oriented. No evidence of aspiration\n Plan:\n Cont to assess. Orient PRN\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Taking Po\ns. UO 15-25 cc hr. , Na 147\n Action:\n Encouraging increased PO\n Response:\n Remains oliguric\n Plan:\n Follow Uo, BUN,creat. Follow Na\n Appitite fair to good. Passed two , colored, OB\n negative stool\n BS clear, diminished at bases. Non-productive, ocas congested cough at\n times.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE RESPIRATORY FAILURE/\n Code status:\n DNR / DNI\n Height:\n 62 Inch\n Admission weight:\n 75.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CVA\n Additional history: CVA with R deficit. Metastatic breast CA(,\n lung, bone,liver) on Coumadin for DVT, Right Mastectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:89\n Temperature:\n 99.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 88 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 830 mL\n 24h total out:\n 525 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:06 AM\n Potassium:\n 3.8 mEq/L\n 04:06 AM\n Chloride:\n 116 mEq/L\n 04:06 AM\n CO2:\n 25 mEq/L\n 04:06 AM\n BUN:\n 16 mg/dL\n 04:06 AM\n Creatinine:\n 0.6 mg/dL\n 04:06 AM\n Glucose:\n 85 mg/dL\n 04:06 AM\n Hematocrit:\n 28.8 %\n 04:06 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: 4 \n Transferred to: 11R\n Date & time of Transfer: @1800\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370492, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n EVENTS: MS has cleared to baseline\n Altered mental status (not Delirium)\n Assessment:\n Pt OX3. Does not recall events of previous 48 hrs. No movement of RUE,\n RLE HX previous stroke. Able to drink liquids, swallow pills\n without any choking\n Action:\n Ongoing assessment\n Response:\n Remains oriented. No evidence of aspiration\n Plan:\n Cont to assess. Orient PRN\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n PO intake improved. UO 15-25 cc hr.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-03-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 370495, "text": "74 year old female w/ metastatic breast cancer (known brain mets), DVT\n on coumadin, prior CVA and cardiomyopathy, who presented w/ altered\n mental status. Since arrival pt has been confused and @ times paranoid\n and hostile toward staff. Head CT ruled out any new acute process and\n confirmed the continued presence of\ninnumerable calcified metastatic\n foci\n EVENTS: MS has cleared to baseline\n Altered mental status (not Delirium)\n Assessment:\n Pt OX3. Does not recall events of previous 48 hrs. No movement of RUE,\n RLE, L side facial, upper body twitch HX previous stroke. Able to\n drink liquids, swallow pills without any choking. ? eti infection,\n meds (on narcs at home), SZ\n Action:\n Ongoing assessment\n Response:\n Remains oriented. No evidence of aspiration\n Plan:\n Cont to assess. Orient PRN\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Taking Po\ns. UO 15-25 cc hr. , Na 147\n Action:\n Encouraging increased PO\n Response:\n Remains oliguric\n Plan:\n Follow Uo, BUN,creat. Follow Na\n" }, { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370263, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n Transfused 1U pRBCs, Hct bumped from 22.6 to _____.\n Minimal urine output, increased to 20cc/hr after blood infusion. Giving\n 500cc bolus of D5HCO3\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 05:55 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: 36.6\nC (97.9\n HR: 87 (79 - 91) bpm\n BP: 98/77(83) {83/14(46) - 133/87(95)} mmHg\n RR: 13 (8 - 20) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,225 mL\n 640 mL\n PO:\n TF:\n IVF:\n 225 mL\n 290 mL\n Blood products:\n 350 mL\n Total out:\n 200 mL\n 72 mL\n Urine:\n 53 mL\n 72 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,025 mL\n 568 mL\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 28 mg/dL\n 113 mEq/L\n 138 mEq/L\n 22.6 %\n 4.5 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 4.5\n Hct\n 22.6\n Plt\n 68\n Cr\n 1.9\n Glucose\n 89\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Differential includes CVA or TIA,\n toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure) or infection (potential sources include lung with\n possible aspiration given decreased mental status over last few days,\n indwelling port, urinary infection, CNS though story is less convincing\n for this), seizures with post-ictal state in setting of brain\n metastases, intracranial hemorrhage. Suspect that some degree is likely\n from poor perfusion in setting of hypovolemia and hypotension. Recent\n use of oxycodone could also be contributing to depressed mental status.\n To pull together the story, suspect this is a case of hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure and narcotics in\n setting of poor substrate and poor reserve leading to deficits as noted\n and exacerbation of old CVA deficits.\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes\n - Renal failure management as discussed below\n - Consider neurology consult in AM if mental status not improved with\n above interventions, would also consider additional imaging such as MRI\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility. In setting of thromcytopenia, anemia, and altered mental\n status, TTP/HUS is also a possibility, but no schistocytes or rise in\n T. Bili. She has no known metastates in the pelvis that would account\n for obstruction.\n - Urine electrolytes being sent\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - Repeat peripheral smear in AM to again check for schistocytes\n - Checking urine eosinophils\n - Currently making fairly good urine, will continue to monitor output\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy.\n - Continue IVF boluses as needed for low urine output or systolic <85,\n or if symptomatic, however will use D5 with three amps of bicarb given\n metabolic acidosis (likely secondary to renal failure), and will need\n to be mindful of her cardiomyopathy.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelet could of 68 on presentation. She is day\n 18 of her gemcitabine therapy, so this could represent marrow\n suppression from that cycle (WBC could be disporportionally up\n secondary to administration of GSC-F). Baseline prior to this appears\n to vary, likely secondary to cycles of chemotherapy (75-400's). TTP/HUS\n is consideration as noted above, but no schistocytes, T. Bili is\n normal, no fevers.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED). Will also rule out hemolysis by checking laboratories, however\n no schistocytes on smear noted.\n - Hemolysis labs, reticulocyte count\n - Type and cross, repeat HCT now and likely transfuse two units of\n PRBCs\n - Checking B12, folate, iron (MCV is 109), as suspect poor nutrition\n intake of these\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Differential includes\n secondary to uremia from renal dysfunction, medication effect (pruritis\n started around same time as she started oxycodone, and reported\n incidence of pruritis is up to 12-13%), worsening liver disease (she\n has known metastases).\n - Checking LFT's, renal failure management as noted above\n - Checking TSH, ferritin\n - Sarna PRN, holding off on benadryl or atarax as these may cloud\n assessment of mental status\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. Bilateral leg pain: Unclear etiology. Patient currently unable to\n give further details. In setting of possible urinary retention, cauda\n equina syndrome is a consideration, but patient currently without\n sensory deficits with normal rectal tone and discomfort with rectal\n thermometer. Response to oxycodone also is less consistent with cord\n compression. She has known bony metastases of her pelvis and spine, so\n these could also be causing pain (eg via nerve impingement or\n pathologic fracture)\n - Start with plain films to rule out compression fracture and/or\n pelvis/hip fracture\n - Consider further imaging of spine in AM if/once patient is more\n stable\n - Should she develop new deficits, would consider initiation of\n steroids for question of cord compression\n - Continue oxycodone for pain control\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370265, "text": "74 year old female with widely metastatic breast cancer (metastases to\n brain, lung, bone, and liver), on coumadin for DVT, history of a with\n right sided deficit, who presented with an acute change in mental\n status, weakness, and word garbling per her husband now with AMS, word\n garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n In Ew she rec\nd total of 2 liters NS. Head CT revealed no acute\n changes. She was placed on meningitis precautions (unable to do LP due\n to ^^ INR). She rec\nd ceftriaxone, vanco and ampicillan prior to admit\n to micu. Of note, her labs show ^ creat to 2.5 and hct 23.5 with\n platelets 68,000. She is a DNR/DNI. She is transferred to micu for\n further management\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Hr 80\ns sr with no vea, bp borderline, 80-90\ns/30-40\ns. Hct 22.6\n urine output minimal 5-10cc/hr\n Action:\n Started on bicarb gtt at 100cc/hr for 2 liters, rec\nd 500cc bolus\n Rec\nd one unit prbc.\n Response:\n Am hct pnding. Repeat creat slightly better than admit.\n Plan:\n Cont to follow creat/hct. Holding lasix/lisinopril for now.\n Altered mental status (not Delirium)\n Assessment:\n Pt is oriented to self only, was oriented to place once but mostly\n disoriented to time and place. Has R facial droop which is old, also\n does not move R side due to previous stroke. L arm normal strength, L\n leg able to move on bed but not able to move off of bed. Speech fairly\n clear. Following all simple commands. Is slightly lethargic at times\n but arouses to verbal stimuli failry easily.\n Action:\n Neuro checks\n Response:\n No changes in neuron status\n Plan:\n Cont to follow.\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370270, "text": "74 year old female with widely metastatic breast cancer (metastases to\n brain, lung, bone, and liver), on coumadin for DVT, history of a with\n right sided deficit, who presented with an acute change in mental\n status, weakness, and word garbling per her husband now with AMS, word\n garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n In Ew she rec\nd total of 2 liters NS. Head CT revealed no acute\n changes/no bleed. She was placed on meningitis precautions (unable to\n do LP due to ^^ INR), which have since been dc\nd. She rec\n ceftriaxone, vanco and ampicillan prior to admit to micu which have all\n been dc\nd. Of note, her labs show ^ creat to 2.5 and hct 23.5 with\n platelets 68,000. She is a DNR/DNI. She is transferred to micu for\n further management\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Hr 80\ns sr with no vea, bp borderline, 80-90\ns/30-40\ns. Hct 22.6\n urine output minimal 5-10cc/hr\n Action:\n Started on bicarb gtt at 100cc/hr for 2 liters, rec\nd 500cc bolus\n Rec\nd one unit prbc.\n Response:\n Am hct ^ 26.9 Repeat creat slightly better than admit.\n Plan:\n Cont to follow creat/hct. Holding lasix/lisinopril for now. Cont to\n follow urine output\n Altered mental status (not Delirium)\n Assessment:\n Pt is oriented to self only, was oriented to place once but mostly\n disoriented to time and place. Has R facial droop which is old, also\n does not move R side due to previous stroke. L arm normal strength, L\n leg able to move on bed but not able to move off of bed. Speech fairly\n clear. Following all simple commands. Is slightly lethargic at times\n but arouses to verbal stimuli failry easily.\n Action:\n Neuro checks\n Response:\n No changes in neuron status\n Plan:\n Cont to follow.\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370343, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n Patient was agitated at the beginning ,family was at bedside,oriented\n to self pulling at clothes and lines,continued to have low grade temps\n HR 150 when pt was agitated Appears to be delirious and paranoid.\n Head Ct from EW\n no acute bleed or stroke.\n Action:\n Continue lactulose for question of hepatic encephalopathy ( however at\n this time unable to give PO\ns poor mental status)NS 500 ml bloused\n and Metoprolol 5 mg/IV and Haldol 1 mg/Iv given with effect.\n Response:\n Patient appears to be calm later, comfortable, follows commands.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370348, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n Patient was agitated most of the night with periods of quiet time in\n between,oriented to self pulling at clothes and lines,speech is not\n clear,c/o pain on lower limbs continued to have low grade temps HR 150\n when pt was agitated Appears to be delirious and paranoid, Head CT\n from EW\n no acute bleed or stroke.\n Action:\n Continue lactulose for question of hepatic encephalopathy ( however at\n this time unable to give PO\ns poor mental status)NS 500 ml bloused\n and Metoprolol 5 mg/IV and Haldol 1 mg/Iv,Benadryl IV,Morphine IV given\n with effect.\n Response:\n Patient appears to be calm later, comfortable, follows commands.\n Plan:\n Pt is DNR/DNI Continue to monitor patient\ns mental status, f/u Cx data\n and electrolytes, IVF hydration\n" }, { "category": "Physician ", "chartdate": "2145-03-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 370471, "text": "Chief Complaint: Altered mental status\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 Improved mental status, less aggitated and beligerant.\n Cooperative, oriented.\n ULTRASOUND - At 03:13 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Vancomycin - 04:50 PM\n Ceftriaxone - 06:37 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:38 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: 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, 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\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:46 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.6\nC (99.6\n HR: 89 (76 - 117) bpm\n BP: 107/46(61) {94/27(47) - 150/102(111)} mmHg\n RR: 17 (10 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,485 mL\n 570 mL\n PO:\n 390 mL\n TF:\n IVF:\n 1,485 mL\n 180 mL\n Blood products:\n Total out:\n 1,353 mL\n 385 mL\n Urine:\n 1,353 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 132 mL\n 185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) 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: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, 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): Ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Right hemiparasis\n Labs / Radiology\n 9.6 g/dL\n 130 K/uL\n 85 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 116 mEq/L\n 147 mEq/L\n 28.8 %\n 4.2 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n 04:06 AM\n WBC\n 4.5\n 4.7\n 5.8\n 4.2\n Hct\n 22.6\n 26.9\n 32.0\n 28.8\n Plt\n 68\n 67\n 106\n 130\n Cr\n 1.9\n 1.7\n 0.8\n 0.6\n Glucose\n 89\n 103\n 77\n 85\n Other labs: PT / PTT / INR:15.8/27.3/1.4, ALT / AST:32/58, Alk Phos / T\n Bili:103/0.9, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.2 g/dL, LDH:411 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n Altered mental status, delerium, confusion.\n ALTERED MENTAL STATUS, DELIRIUM -- Subactue onset. Attributed to\n toxic-metabolic dysfunction in setting of infection/sepsis, with\n possible contribution of medication effect (Levofloxicin, narcotics) on\n background of prior CVA. Also consider seizure with post-ictal or\n confusional state --> consider EEG.\n HYPOVOLEMIA (VOLUME DEPLETION -- improved. Monitor.\n HYPOCALCEMIA -- mild. Check ionized. Repleted.\n PRURITIS -- symptomatic treatment. Resolved.\n AGGITATION -- resolved.\n RENAL FAILURE -- acute, resolving with iv fluids. Monitor.\n MALIGNANCY -- extensive, widely metastatic.\n Possible INFECTION -- indwelling iv catheter --> line related\n infection. new LLL infiltrate --> Empirical antimicrobials.\n h/o DVT -- resume coumadin, monitor PT on coumadin.\n NUTRITIONAL SUPPORT -- resume PO under supervision. Consider formal\n speech/swallow evaluation if concern.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\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 :Transfer to floor\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370255, "text": "74 year old female with widely metastatic breast cancer (metastases to\n brain, lung, bone, and liver), on coumadin for DVT, history of a with\n right sided deficit, who presented with an acute change in mental\n status, weakness, and word garbling per her husband now with AMS, word\n garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n In Ew she rec\nd total of 2 liters NS. Head CT revealed no acute\n changes. She was placed on meningitis precautions (unable to do LP due\n to ^^ INR). She rec\nd ceftriaxone, vanco and ampicillan prior to admit\n to micu. Of note, her labs show ^ creat to 2.3 and hct 23.5 with\n platelets 68,000. She is a DNR/DNI. She is transferred to micu for\n further management\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Hr 80\ns sr with no vea, bp borderline, 80-90\ns/30-40\ns. Hct 22.6\n urine output minimal 5-10cc/hr\n Action:\n Started on bicarb gtt at 100cc/hr for 2 liters. Rec\nd one unit prbc.\n Response:\n Am hct pnding. Repeat creat slightly better than admit.\n Plan:\n Cont to follow creat/hct. Holding lasix/lisinopril for now.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370341, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n patent was agitated at the beginning ,family was at bedside,oriented to\n self pulling at clothes and lines. Appears to be delirious and\n paranoid. Head Ct from EW\n no acute bleed or stroke.\n Action:\n Continue lactulose for question of hepatic encephalopathy ( however at\n this time unable to give PO\ns poor mental status)\n Response:\n patient appears to be calm by herself later, comfortable, follows\n commands and converses w/family members.\n :\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370336, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, pulling at clothes and\n lines. Appears to be delirious and paranoid. Per husband similar\n episodes happened before, however this one is more severe. Head Ct from\n EW\n no acute bleed or stroke.\n Action:\n Haldol/ morphine/ benadryl given. Continue lactulose for question of\n hepatic encephalopathy ( however at this time unable to give PO\ns \n poor mental status)\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/family members.\n :\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing. On\n CXR\n possible LT PNA. Will start abx.\n Cardio: B/P 80-100\ns (baseline 80-90\ns) HR at 90-100\ns SR/ST while\n agitated up to 130\ns. RT leg edema. Pulses present. INR supratheraputic\n at 5.3. Will get another 1U pRBCs and 1L D5HCO3 for low urine output\n with BPs in 80s-90s. (Goal: Continue D5 Bicarb/blood boluses as needed\n for low urine output or systolic <85, or if symptomatic)\n GI: abd soft non tender, positive for BS. NPO for now poor MS.\n : amber color urine via foley minimal amnt 10-20cc/hr. bolus\n fluid/blood prn UOP\n Skin: multiple ecchymotic areas. : Platelets 68 on presentation.\n INR-5.3. c/o itching\n lotion applied and benadryl given\n w/positive effect.\n IV access: LT chest porthacath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Physician ", "chartdate": "2145-03-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 370241, "text": "Chief Complaint: altered mental status\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 74 yo female with widely met breast CA (, , spine) and DVT on\n coumadin, hx CVA with right pareis. Well until a week ago, with\n bilateral thigh pain- given oxycodone with improvement, but with\n diffuse itching.\n Yesterday, was lethargic with left sided weakness, requiring assistance\n to get out of the car, slurred speech. This am, she had slurred speech\n and was brought in for evaluation.\n No urination x 24 hours with poor po intake over past several weeks.\n ED: afebrile, BP 102/80, P86, 98%, R16. BP 67-93. Receied 3 liters NS\n with partial response.\n Oncology team: rec'd abx for meningitis- CTX/Vanc/ampicillin\n Head CT without bleed for edema\n Labs notable for anemia: 23, ARF (2.5, up from baseline 0.5), INR 4.2\n Patient admitted from: ER\n History obtained from Medical records, ICU housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 'statin, carvedilol, folic acid, lasix 20 mg qod, lisinopril, ambien,\n aspirin, coumadin 5 mg, oxycodone , lacutlose, percocet\n Past medical history:\n Family history:\n Social History:\n Metsatatic breast cancer dx'd in \n *Hx of adriamycin cardiotoxity, most recent lvef 50-55%\n *Most recent chemo Gemcytobine \n Hx CVA with right hemiparesis\n DVT on coumadin\n Father with rectal cancer\n Occupation:\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: Married, lives with husband, mostly bed-bound\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, poor po intake\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia\n Nutritional Support: No(t) NPO, No(t) Tube feeds\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) Diarrhea,\n 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, Rash, itchy skin\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious\n Flowsheet Data as of 11:19 PM\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: 86 (86 - 91) bpm\n BP: 83/35(48) {83/14(47) - 133/87(95)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,107 mL\n PO:\n TF:\n IVF:\n 107 mL\n Blood products:\n Total out:\n 0 mL\n 180 mL\n Urine:\n 33 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,927 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n General Appearance: Elderly, chroncially ill\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) Endotracheal tube, No(t)\n NG tube, No(t) OG tube, slighlty dry MM with asymmetrical nasolabial\n fold\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal), (S2:\n Normal), 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: occasional rales at bases; porta-cath\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: trace, No(t) Cyanosis, No(t) Clubbing,\n venous stasis\n Musculoskeletal: Muscle wasting\n Skin: Cool, No(t) Rash: , No(t) Jaundice, excoriations from itching\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n voice, Oriented (to): person, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal, right LE and UE 3-4/5\n Labs / Radiology\n 68 K/uL\n 22.6 %\n 7.4 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 28 mg/dL\n 18 mEq/L\n 113 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 4.5 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 4.5\n Hct\n 22.6\n Plt\n 68\n Cr\n 1.9\n Glucose\n 89\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:89, Band:0, Fibrinogen:373 mg/dL,\n Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: ED labs: BUN/Cr 30/2.3\n U/A: sg 1.022, tr ketone, tr LE, WBC, several casts\n lactate 0.8;\n Imaging: Head CT: no bleeds/infarcts\n CXR: left pleural effusion\n Assessment and Plan\n 74 yo female with metastatic breast CA, CM, hx DVT, hx CVA\n 1. Altered mental status: head CT negative for an acute process.\n Possible etiologies include toxic metabolic, hypoperfusion/TIA,\n medication effects\n *Hydrate with IVF\n *Consider repeat neuro-imaging if mental status does not improve\n 2. Hypotension: pt\ns BP is chronically low with SBP 80-90\ns and\n also appears volume depleted. Will resuscitate with IVF. If volume\n overload becomes a limiting factor, will consider pressors to maintain\n MAP>65\n Consider stem to r/o adrenal insufficiency- no known adrenal\n mets, but last CT done 3-4 months ago\n 3. Acute renal failure: most likely pre-renal due to diminished\n po intake and ongoing diuretics\n - Foley placed with good urine output, urine lytes pending, obtain abd\n US if Cr does not decrease with hydration\n 4. Anemia: will transfuse 1 unit pRBC\n 5. Breast cancer_ oncology team following\n 6. DVT: INR supratherapeutic- hold coumadin and allow values to\n drift down\n Rest of plan per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: systemic anticoagulation with coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI but pressors ok\n Disposition: ICU\n Total time spent: 35 minutes\n Pt is criticlaly ill\n" }, { "category": "Physician ", "chartdate": "2145-03-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370242, "text": "Chief Complaint: Altered mental status\n HPI:\n Ms. is a 74 year old female with widely metastatic breast\n cancer (metastases to brain, lung, , and liver), on coumadin for\n DVT, history of a with right sided deficit, who presented with an acute\n change in mental status, weakness, and word garbling per her husband\n now with AMS, word garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n .\n Yesterday, she went for an INR check and felt lethargic and weak. Her\n weakness was more notable on her left side, which is usually her\n stronger side. She was unable to get out of the car without significant\n assistance. She was noted to be slurring her speech, but otherwise was\n making sense. At the clinic, the nursing team had a difficult time\n obtaining blood. She then reported she wanted to go home and go to bed.\n She then went to bed, and per her husband, awoke later than usual in\n the morning, around 10 AM. He noticed at that time her face was\n asymetric, especially her mouth. She again had difficulty speaking and\n it was apparently difficult to get the words out. She did not want\n breakfast, and her husband fed her breakfast. At this time, her husband\n was concerned and brought her in for evaluation. He states she has not\n urinated since yesterday. There had been no changes in her urine noted.\n She has poor PO intake, usually only eating breakfast, with poor fluid\n intake. She was also recently started on Megace, which was stopped\n about one week ago due to an elevated INR.\n .\n In the emergency department, her initial vital signs were: temperature\n of 98.1, blood pressure of 102/80, heart rate of 86, respiratory rate\n of 16, and oxygen saturation of 98% on room air. While in the\n emergency room, her blood pressure flucuated from 67 systolic to 93\n systolic. She received a total of three liters of IVF for intermittent\n hypotension, with fair response. She was given 2 grams of ceftriaxone,\n 1 gram of vancomycin, 2 grams of ampicillin, 25 mg of benadryl, and\n percocet 5/325 mg times two.\n .\n She was noted to have a right-sided facial droop, which per report was\n old. She was guaiac negative. A head CT was without a bleed or edema.\n Her laboratories were remarkable for thrombocytopenia, anemia, and new\n renal failure. An urinanalysis was unremarkable. She was started on\n empiric antibiotic coverage for bacterial meningitis emergency room\n physician discussed her case with on-call hematology/oncology fellow. A\n lumbar puncture was not pursued as her INR was 4.2, and it was felt\n this was no consistent with her goals of care.\n .\n While she was in the emergency room, her mental status may have\n improved somewhat, but she is not back to her baseline. Upon sign-out\n to ICU team, ampicillin for listeria coverage was discussed and given\n prior to leaving the ED.\n .\n Of note, her last gemcitabine therapy was on , with neupogen\n given on and . Per report from her husband, this therapy is no\n longer working, and a different therapy plan will be pursued in the\n coming weeks after a break from any therapies.\n .\n Upon arrival to the ICU, patient's blood pressure was 102/46. She\n denied any discomfort and would answer some questions appropriately.\n Home medications:\n 1. Atorvastatin 20 mg PO DAILY\n 2. Carvedilol 3.125 mg PO DAILY\n 3. Folic Acid 1 mg PO DAILY\n 4. Furosemide 20 mg PO EVERY OTHER DAY\n 5. Lisinopril 5 mg PO DAILY\n 6. Zolpidem 5 mg PO HS prn\n 7. Aspirin 81 mg PO DAILY\n 8. Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn\n 9. Coumadin 5 mg PO once a day\n 10. Oxycodone 20mg SR qhs prn\n 11. Lactulose 30ml prn\n 12. Oxycodone-Acetaminophen 5 mg-325 mg 1-2t PO q4 prn\n ALLERGIES: Patient previously reported an allergy to shellfish and\n iodinated contrast, however per OMR, she has confirmed since then,\n along with her husband, that she is not allergic and can tolerate CTs\n with contrast\n Past medical history:\n Oncologic History:\n - Diagnosed with breast cancer in , initially diagnosed as\n inflammatory breast cancer\n - ER positive\n - Received neoadjuvant doxorubicin and taxotere, followed by\n right mastectomy and radiation\n - Initially on Tamoxifen x 2 years (started )\n - developed sclerotic lesion of right proximal humerus;\n treated with XRT and switched from Tamoxifen to Arimidex\n - : scan revealed extensive areas of increased\n uptake, likely bony metastases\n - started Clinical Trial 03-410, estradiol followed by\n fulvestrant in postmenopausal women with ER positive metastatic\n breast cancer\n - : CT torso indicated increased metastases, with\n pulmonary nodules, liver lesions, and diffuse bony involvement\n - : Taxol/Avastin, then single Taxol\n - : Started on Xeloda\n - / CMF (cyclophosphamide, methotrexate, 5-FU)\n - Received whole brain radiation in for known CNS\n metastases\n - / Navelbine\n - / 11 cycles of Doxil\n - - gemcitabine x 5 cycles\n - started XRT for two posterior fossa metastases\n .\n Past Medical History:\n 1. Cardiomyopathy secondary to Adriamycin. Most recent echo \n shows mild regional left ventricular systolic dysfunction. No\n pathologic valvular abnormality or significant outflow tract\n gradient seen. Mild pulmonary artery systolic hypertension, LVEF\n probably similar to previous (50%). Followed by Dr. .\n 2. Osteoarthritis, s/p 2 knee replacements, and another in \n 3. Lymphedema\n 4. CVA with right hemiparesis, 12/. Followed by Dr. .\n 5. DVT on coumadin therapy\n Family history:\n The patient's father died of rectal cancer.\n Social History:\n Patient does not smoke tobacco or use illicit drugs. Per OMR notes, she\n drinks a glass of wine a few times a week. She lives with her husband,\n and mainly bed-bound.\n Review of systems:\n Review of systems is otherwise negative for fevers, recent illness,\n chills, nightsweats, nausea, vomiting, diarrhea, constipation, chest\n pain, shortness of breath. No neck stiffness, headache, visual\n symptoms.\n Flowsheet Data as of 10:23 PM\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: 86 (86 - 91) bpm\n BP: 83/35(48) {83/14(47) - 133/87(95)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,029 mL\n PO:\n TF:\n IVF:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 180 mL\n Urine:\n 33 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,849 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 28 mg/dL\n 18 mEq/L\n 113 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 22.6 %\n 4.5 K/uL\n [image002.jpg]\n \n 2:33 A3/28/ 08:16 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 4.5\n Hct\n 22.6\n Plt\n 68\n Cr\n 1.9\n Glucose\n 89\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n IMAGING:\n Chest x-ray\n 1. Left lower lobe opacity may represent pneumonia or edema. Recommend\n repeat\n imaging after diuresis to excluded underlying infection.\n 2. Minimal CHF.\n 3. Moderate left and small right pleural effusion.\n .\n EKG: Sinus, LBBB, normal axis, LVH, TW flattening in II, III, aVF and\n aVL.\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Differential includes CVA or TIA,\n toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure) or infection (potential sources include lung with\n possible aspiration given decreased mental status over last few days,\n indwelling port, urinary infection, CNS though story is less convincing\n for this), seizures with post-ictal state in setting of brain\n metastases, intracranial hemorrhage. Suspect that some degree is likely\n from poor perfusion in setting of hypovolemia and hypotension. Recent\n use of oxycodone could also be contributing to depressed mental status.\n To pull together the story, suspect this is a case of hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure and narcotics in\n setting of poor substrate and poor reserve leading to deficits as noted\n and exacerbation of old CVA deficits.\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes\n - Renal failure management as discussed below\n - Consider neurology consult in AM if mental status not improved with\n above interventions, would also consider additional imaging such as MRI\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility. In setting of thromcytopenia, anemia, and altered mental\n status, TTP/HUS is also a possibility, but no schistocytes or rise in\n T. Bili. She has no known metastates in the pelvis that would account\n for obstruction.\n - Urine electrolytes being sent\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - Repeat peripheral smear in AM to again check for schistocytes\n - Checking urine eosinophils\n - Currently making fairly good urine, will continue to monitor output\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy.\n - Continue IVF boluses as needed for low urine output or systolic <85,\n or if symptomatic, however will use D5 with three amps of bicarb given\n metabolic acidosis (likely secondary to renal failure), and will need\n to be mindful of her cardiomyopathy.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelet could of 68 on presentation. She is day\n 18 of her gemcitabine therapy, so this could represent marrow\n suppression from that cycle (WBC could be disporportionally up\n secondary to administration of GSC-F). Baseline prior to this appears\n to vary, likely secondary to cycles of chemotherapy (75-400's). TTP/HUS\n is consideration as noted above, but no schistocytes, T. Bili is\n normal, no fevers.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED). Will also rule out hemolysis by checking laboratories, however\n no schistocytes on smear noted.\n - Hemolysis labs, reticulocyte count\n - Type and cross, repeat HCT now and likely transfuse two units of\n PRBCs\n - Checking B12, folate, iron (MCV is 109), as suspect poor nutrition\n intake of these\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Differential includes\n secondary to uremia from renal dysfunction, medication effect (pruritis\n started around same time as she started oxycodone, and reported\n incidence of pruritis is up to 12-13%), worsening liver disease (she\n has known metastases).\n - Checking LFT's, renal failure management as noted above\n - Checking TSH, ferritin\n - Sarna PRN, holding off on benadryl or atarax as these may cloud\n assessment of mental status\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. Bilateral leg pain: Unclear etiology. Patient currently unable to\n give further details. In setting of possible urinary retention, cauda\n equina syndrome is a consideration, but patient currently without\n sensory deficits with normal rectal tone and discomfort with rectal\n thermometer. Response to oxycodone also is less consistent with cord\n compression. She has known bony metastases of her pelvis and spine, so\n these could also be causing pain (eg via nerve impingement or\n pathologic fracture)\n - Start with plain films to rule out compression fracture and/or\n pelvis/hip fracture\n - Consider further imaging of spine in AM if/once patient is more\n stable\n - Should she develop new deficits, would consider initiation of\n steroids for question of cord compression\n - Continue oxycodone for pain control\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left leg\n Stress ulcer: PPI\n VAP: N/A\n Comments: N/A\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition: level of care for now until further hemodynamically\n stable.\n" }, { "category": "Physician ", "chartdate": "2145-03-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 370239, "text": "Chief Complaint: Altered mental status\n HPI:\n Ms. is a 74 year old female with widely metastatic breast\n cancer (metastases to brain, lung, bone, and liver), on coumadin for\n DVT, history of a with right sided deficit, who presented with an acute\n change in mental status, weakness, and word garbling per her husband\n now with AMS, word garbling, and weakness per husband.\n .\n Per report from her husband, patient was doing well until one week ago.\n At that time she developed bilateral sharp shooting pain in her thighs,\n radiating up to her pelvis and inguinal area. She spoke with her\n oncology team, and was given a prescription for oxycodone 20 mg, which\n she took . She also developed diffuse itchiness around the same\n time, but no rash. She has continued to have pain that is responsive to\n oxycodone.\n .\n Yesterday, she went for an INR check and felt lethargic and weak. Her\n weakness was more notable on her left side, which is usually her\n stronger side. She was unable to get out of the car without significant\n assistance. She was noted to be slurring her speech, but otherwise was\n making sense. At the clinic, the nursing team had a difficult time\n obtaining blood. She then reported she wanted to go home and go to bed.\n She then went to bed, and per her husband, awoke later than usual in\n the morning, around 10 AM. He noticed at that time her face was\n asymetric, especially her mouth. She again had difficulty speaking and\n it was apparently difficult to get the words out. She did not want\n breakfast, and her husband fed her breakfast. At this time, her husband\n was concerned and brought her in for evaluation. He states she has not\n urinated since yesterday. There had been no changes in her urine noted.\n She has poor PO intake, usually only eating breakfast, with poor fluid\n intake. She was also recently started on Megace, which was stopped\n about one week ago due to an elevated INR.\n .\n In the emergency department, her initial vital signs were: temperature\n of 98.1, blood pressure of 102/80, heart rate of 86, respiratory rate\n of 16, and oxygen saturation of 98% on room air. While in the\n emergency room, her blood pressure flucuated from 67 systolic to 93\n systolic. She received a total of three liters of IVF for intermittent\n hypotension, with fair response. She was given 2 grams of ceftriaxone,\n 1 gram of vancomycin, 2 grams of ampicillin, 25 mg of benadryl, and\n percocet 5/325 mg times two.\n .\n She was noted to have a right-sided facial droop, which per report was\n old. She was guaiac negative. A head CT was without a bleed or edema.\n Her laboratories were remarkable for thrombocytopenia, anemia, and new\n renal failure. An urinanalysis was unremarkable. She was started on\n empiric coverage for bacterial meningitis and was given 1 gram of\n vancomycin and 1 gram of ceftriaxone after recommendations given by the\n oncology team to the emergency room physicians. A lumbar puncture was\n not pursued as her INR was 4.2, and it was felt this was no consistent\n with her goals of care.\n .\n While she was in the emergency room, her mental status may have\n improved somewhat, but she is not back to her baseline. Upon sign-out\n to ICU team, ampicillin for listeria coverage was discussed and given\n prior to leaving the ED.\n .\n Of note, her last gemcitabine therapy was on , with neupogen\n given on and . Per report from her husband, this therapy is no\n longer working, and a different therapy plan will be pursued in the\n coming weeks.\n .\n Upon arrival to the ICU, patient's blood pressure was 102/46. She\n denied any discomfort and would answer some questions appropriately.\n Home medications:\n 1. Atorvastatin 20 mg PO DAILY\n 2. Carvedilol 3.125 mg PO DAILY\n 3. Folic Acid 1 mg PO DAILY\n 4. Furosemide 20 mg PO EVERY OTHER DAY\n 5. Lisinopril 5 mg PO DAILY\n 6. Zolpidem 5 mg PO HS prn\n 7. Aspirin 81 mg PO DAILY\n 8. Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H prn\n 9. Coumadin 5 mg PO once a day\n 10. Oxycodone 20mg SR qhs prn\n 11. Lactulose 30ml prn\n 12. Oxycodone-Acetaminophen 5 mg-325 mg 1-2t PO q4 prn\n ALLERGIES: Patient previously reported an allergy to shellfish and\n iodinated contrast, however per OMR, she has confirmed since then,\n along with her husband, that she is not allergic and can tolerate CTs\n with contrast\n Past medical history:\n Oncologic History:\n - Diagnosed with breast cancer in , initially diagnosed as\n inflammatory breast cancer\n - ER positive\n - Received neoadjuvant doxorubicin and taxotere, followed by\n right mastectomy and radiation\n - Initially on Tamoxifen x 2 years (started )\n - developed sclerotic lesion of right proximal humerus;\n treated with XRT and switched from Tamoxifen to Arimidex\n - : Bone scan revealed extensive areas of increased\n uptake, likely bony metastases\n - started Clinical Trial 03-410, estradiol followed by\n fulvestrant in postmenopausal women with ER positive metastatic\n breast cancer\n - : CT torso indicated increased metastases, with\n pulmonary nodules, liver lesions, and diffuse bony involvement\n - : Taxol/Avastin, then single Taxol\n - : Started on Xeloda\n - / CMF (cyclophosphamide, methotrexate, 5-FU)\n - Received whole brain radiation in for known CNS\n metastases\n - / Navelbine\n - / 11 cycles of Doxil\n - - gemcitabine x 5 cycles\n - started XRT for two posterior fossa metastases\n .\n Past Medical History:\n 1. Cardiomyopathy secondary to Adriamycin. Most recent echo \n shows mild regional left ventricular systolic dysfunction. No\n pathologic valvular abnormality or significant outflow tract\n gradient seen. Mild pulmonary artery systolic hypertension, LVEF\n probably similar to previous (50%). Followed by Dr. .\n 2. Osteoarthritis, s/p 2 knee replacements, and another in \n 3. Lymphedema\n 4. CVA with right hemiparesis, 12/. Followed by Dr. .\n 5. DVT on coumadin therapy\n 6. CVA in with residual right sided deficit\n Family history:\n The patient's father died of rectal cancer.\n Social History:\n Patient does not smoke tobacco or use illicit drugs. Per OMR notes, she\n drinks a glass of wine a few times a week. She lives with her husband,\n and mainly bed-bound.\n Review of systems:\n Review of systems is otherwise negative for fevers, recent illness,\n chills, nightsweats, nausea, vomiting, diarrhea, constipation, chest\n pain, shortness of breath.\n Flowsheet Data as of 10:23 PM\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: 86 (86 - 91) bpm\n BP: 83/35(48) {83/14(47) - 133/87(95)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,029 mL\n PO:\n TF:\n IVF:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 180 mL\n Urine:\n 33 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,849 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at RUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 28 mg/dL\n 18 mEq/L\n 113 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 22.6 %\n 4.5 K/uL\n [image002.jpg]\n \n 2:33 A3/28/ 08:16 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 4.5\n Hct\n 22.6\n Plt\n 68\n Cr\n 1.9\n Glucose\n 89\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n IMAGING:\n Chest x-ray\n 1. Left lower lobe opacity may represent pneumonia or edema. Recommend\n repeat\n imaging after diuresis to excluded underlying infection.\n 2. Minimal CHF.\n 3. Moderate left and small right pleural effusion.\n .\n EKG: Sinus, LBBB, normal axis, LVH, TW flattening in II, III, aVF and\n aVL.\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, and cardiomyopathy, who\n presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Differential includes CVA or TIA,\n toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure) or infection (potential sources include lung with\n possible aspiration given decreased mental status over last few days,\n indwelling port, urinary infection, CNS though story is less convincing\n for this), seizures with post-ictal state in setting of brain\n metastases, intracranial hemorrhage. Suspect that some degree is likely\n from poor perfusion in setting of hypovolemia and hypotension. Recent\n use of oxycodone could also be contributing to depressed mental status.\n - Per oncology, will continue to cover for bacterial meningitis with\n vancomycin, ceftriaxone, and ampicillin, though no true signs of\n meningmus on exam and history less consistent with this. Will likely\n need to re-dose medications as renal function improves.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - Renal failure management as discussed below\n - Consider neurology consult in AM if mental status not improved with\n above interventions, would also consider additional imaging such as MRI\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility. In setting of thromcytopenia, anemia, and altered mental\n status, TTP/HUS is also a possibility, but no schistocytes or rise in\n T. Bili. She has no known metastates in the pelvis that would account\n for obstruction.\n - Urine electrolytes being sent\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - Repeat peripheral smear in AM to again check for schistocytes\n - Checking urine eosinophils\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's.\n - Continue IVF boluses as needed for low urine output or systolic <85,\n or if symptomatic, however will use D5 with three amps of bicarb given\n metabolic acidosis (likely secondary to renal failure), and will need\n to be mindful of her cardiomyopathy.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelet could of 68 on presentation. She is day\n 18 of her gemcitabine therapy, so this could represent marrow\n suppression from that cycle (WBC could be disporportionally up\n secondary to administration of GSC-F). Baseline prior to this appears\n to vary, likely secondary to cycles of chemotherapy (75-400's).\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED). Will also rule out hemolysis by checking laboratories, however\n no schistocytes on smear noted.\n - Hemolysis labs, reticulocyte count\n - Type and cross, repeat HCT now and likely transfuse two units of\n PRBCs\n - Checking B12, folate, iron (MCV is 109), as suspect poor nutrition\n intake of these\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Differential includes\n secondary to uremia from renal dysfunction, medication effect (pruritis\n started around same time as she started oxycodone, and reported\n incidence of pruritis is up to 12-13%), worsening liver disease (she\n has known metastases).\n - Checking LFT's, renal failure management as noted above\n - Checking TSH, ferritin\n - Sarna PRN, holding off on benadryl or atarax as these may cloud\n assessment of mental status\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. Bilateral leg pain: Unclear etiology. Patient currently unable to\n give further details. In setting of possible urinary retention, cauda\n equina syndrome is a consideration, but patient currently without\n sensory deficits with normal rectal tone and discomfort with rectal\n thermometer. Response to oxycodone also is less consistent with cord\n compression. She has known bony metastases of her pelvis and spine, so\n these could also be causing pain (eg via nerve impingement or\n pathologic fracture)\n - Start with plain films to rule out compression fracture and/or\n pelvis/hip fracture\n - Consider further imaging of spine in AM if/once patient is more\n stable\n - Should she develop new deficits, would consider initiation of\n steroids for question of cord compression\n - Continue oxycodone for pain control\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left leg\n Stress ulcer: PPI\n VAP: N/A\n Comments: N/A\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition: level of care for now until further hemodynamically\n stable.\n" }, { "category": "Nutrition", "chartdate": "2145-03-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 370308, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 75.1 kg\n 30.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 150\n 56kg\n 74.8kg (), 78.5kg ()\n Diagnosis:\n PMH : Mets Breast CA dx'd (mets to brain, lung, liver), s/p\n chemo/XRT & R. mastectomy, DVT, CVA , cardiomyopatthy, OA s/p knee\n replacement x2, lymphedema\n Food allergies and intolerances: none noted.\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 05:37 AM\n BUN\n 28 mg/dL\n 05:37 AM\n Creatinine\n 1.7 mg/dL\n 05:37 AM\n Sodium\n 137 mEq/L\n 05:37 AM\n Potassium\n 4.6 mEq/L\n 05:37 AM\n Chloride\n 111 mEq/L\n 05:37 AM\n TCO2\n 20 mEq/L\n 05:37 AM\n Albumin\n 2.6 g/dL\n 08:16 PM\n Calcium non-ionized\n 7.6 mg/dL\n 05:37 AM\n Phosphorus\n 4.1 mg/dL\n 05:37 AM\n Magnesium\n 2.3 mg/dL\n 05:37 AM\n ALT\n 50 IU/L\n 08:16 PM\n Alkaline Phosphate\n 124 IU/L\n 08:16 PM\n AST\n 82 IU/L\n 08:16 PM\n Total Bilirubin\n 0.4 mg/dL\n 08:16 PM\n WBC\n 4.7 K/uL\n 05:37 AM\n Hgb\n 9.2 g/dL\n 05:37 AM\n Hematocrit\n 26.9 %\n 05:37 AM\n Current diet order / nutrition support: NPO pending tube feeds c/s\n GI:\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, Low protein stores, mets CA\n & age.\n Estimated Nutritional Needs\n Calories: 1232-1568 (BEE x or / 22-28 cal/kg)\n Protein: 56-84 (1-1.5 g/kg)\n Fluid: per team\n Specifics:\n 74 YO female with hx of mets breast \n Medical Nutrition Therapy Plan - Recommend the Following\n" }, { "category": "Nutrition", "chartdate": "2145-03-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 370309, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 157 cm\n 75.1 kg\n 30.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 49.9 kg\n 150\n 56kg\n 74.8kg (), 78.5kg ()\n Diagnosis: Acute respiratory failure\n PMH : Mets Breast CA dx'd (mets to brain, lung, liver), s/p\n chemo/XRT & R. mastectomy, DVT, CVA , cardiomyopatthy, OA s/p knee\n replacement x2, lymphedema\n Food allergies and intolerances: none noted.\n Pertinent medications: FA, lactulose, Abx\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 05:37 AM\n BUN\n 28 mg/dL\n 05:37 AM\n Creatinine\n 1.7 mg/dL\n 05:37 AM\n Sodium\n 137 mEq/L\n 05:37 AM\n Potassium\n 4.6 mEq/L\n 05:37 AM\n Chloride\n 111 mEq/L\n 05:37 AM\n TCO2\n 20 mEq/L\n 05:37 AM\n Albumin\n 2.6 g/dL\n 08:16 PM\n Calcium non-ionized\n 7.6 mg/dL\n 05:37 AM\n Phosphorus\n 4.1 mg/dL\n 05:37 AM\n Magnesium\n 2.3 mg/dL\n 05:37 AM\n ALT\n 50 IU/L\n 08:16 PM\n Alkaline Phosphate\n 124 IU/L\n 08:16 PM\n AST\n 82 IU/L\n 08:16 PM\n Total Bilirubin\n 0.4 mg/dL\n 08:16 PM\n WBC\n 4.7 K/uL\n 05:37 AM\n Hgb\n 9.2 g/dL\n 05:37 AM\n Hematocrit\n 26.9 %\n 05:37 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, Low protein stores, mets CA\n & age.\n Estimated Nutritional Needs\n Calories: 1232-1568 (BEE x or / 22-28 cal/kg)\n Protein: 56-84 (1-1.5 g/kg)\n Fluid: per team\n Specifics:\n 74 YO female with hx of mets breast CA p/w respiratory failure & MS\n changes. Consulted for poor po\ns but currently NPO. Recommend enteral\n feeds if within patients plan of care. If tube feeds, consider\n Fibersource HN at goal 45mL/hr (1296kcals/57g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If tube feed is being considered, start at 15mL/hr, advance by\n 10mL Q 6hrs to goal 45mL/hr of Fibersource HN\n 2. check residuals Q 4hrs 7 hold x1hr if >100mL\n 3. Monitor labs & hydration\n" }, { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370304, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n Transfused 1U pRBCs, Hct bumped from 22.6 to 26.9.\n Minimal urine output, increased to 20cc/hr after blood infusion. Giving\n 500cc bolus of D5HCO3\n This morning agitated, screaming, pulling at clothes and lines,\n appeared paranoid. Per husband, has happened previously and responded\n to pain meds.\n Given Haldol 1mg IV, Morphine 2mg IV and benadryl 25mg IV.\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 05:55 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: 36.6\nC (97.9\n HR: 87 (79 - 91) bpm\n BP: 98/77(83) {83/14(46) - 133/87(95)} mmHg\n RR: 13 (8 - 20) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,225 mL\n 640 mL\n PO:\n TF:\n IVF:\n 225 mL\n 290 mL\n Blood products:\n 350 mL\n Total out:\n 200 mL\n 72 mL\n Urine:\n 53 mL\n 72 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,025 mL\n 568 mL\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 67 K/uL\n 7.4 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 5.5\n 4.5\n 4.7\n Hct\n 23.5\n 22.6\n 26.9\n Plt\n 68\n 68\n 67\n Cr\n 2.3\n 1.9\n 1.7\n Glucose\n 111\n 89\n 103\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL.\n Retic 0.5, Fibrinogen 373, Iron 39, TIBC 164, Folate, Ferritin, B12 >\n assay, TSH 3.1\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Likely hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure, worsening LFT\n abnormalities and narcotics in setting of poor substrate and poor\n reserve leading to deficits as noted and exacerbation of old CVA\n deficits.\n Other likely contributors contributors:\n - toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure and worsening LFTs)\n - left lower lobe infiltrate, likely aspiration\n Les likely contributors:\n - CVA or TIA, (CT head prelim neg)\n - infection of indwelling port, urine (UA bland), CNS (no consistent\n symptoms)\n - seizures with post-ictal state in setting of brain metastases\n - intracranial hemorrhage/mass effect/edema (no evidence on CT scan)\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed.\n - Will continue to monitor and unless starts to bleed\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\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:\n Mrs has had one unit pRBC's with some improvement in HCt and\n renal function. She continues to be quite agitated and complains of\n pruritus. She denies pain. Her husband is at her bedside.\n Exam notable for frail elderly woman with BP of 98/77 HR of 104 RR of\n 24 with sats of 100% on RA. Her MM are dry and she has clear lung\n sounds with a supple neck. kegs are edematous and wih some anterior\n bruising.\n Labs notable for WBC of 4.7 K, HCT 26.9 , K+4.6 , Cr 1.7 , lactate<\n 2.0 and INR of 5.3 CXR with possible infiltrate at left base but no\n evidence for interstitial edema.\n Agree with plan to support with IVF's, blood products and antibiotics\n for possible aspiration PNA. LFT's, renal function will hopefully\n improve over next 24 hrs. If mental status does not improve, then EEG\n may be necessary. Dr will be consulted who follows her closely.\n She may need hospice level care if she does not improve over next 48\n hrs.\n Remainder of plan as outlined above. Husband has been updated regarding\n plans today\n Patient is critically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 01:35 PM ------\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370311, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, pulling at clothes and\n lines. Appears to be delirious and paranoid. Per husband similar\n episodes happened before, however this one is more severe. Head Ct from\n EW\n no acute bleed or stroke.\n Action:\n Haldol/ morphine/ benadryl given. Continue lactulose for question of\n hepatic encephalopathy ( however at this time unable to give PO\ns \n poor mental status)\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/family members.\n :\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing. On\n CXR\n possible LT PNA. Will start abx.\n Cardio: B/P 80-100\ns (baseline 80-90\ns) HR at 90-100\ns SR/ST while\n agitated up to 130\ns. RT leg edema. Pulses present. INR supratheraputic\n at 5.3. Will get another 1U pRBCs and 1L D5HCO3 for low urine output\n with BPs in 80s-90s. (Goal: Continue D5 Bicarb/blood boluses as needed\n for low urine output or systolic <85, or if symptomatic)\n GI: abd soft non tender, positive for BS. NPO for now poor MS.\n : amber color urine via foley minimal amnt 10-20cc/hr. bolus\n fluid/blood prn UOP\n Skin: multiple ecchymotic areas. : Platelets 68 on presentation.\n INR-5.3. c/o itching\n lotion applied and benadryl given\n w/positive effect.\n IV access: LT chest porthacath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2145-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370297, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, pulling at clothes and\n lines. Appears to be delirious and paranoid. Per husband similar\n episodes happened before, however this one is more severe. Head Ct from\n EW\n no acute bleed or stroke.\n Action:\n Haldol/ morphine/ benadryl given. Continue lactulose for question of\n hepatic encephalopathy ( however at this time unable to give PO\ns \n poor mental status)\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/family members.\n :\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing. On\n CXR\n possible LT PNA. Will start abx.\n Cardio: B/P 80-100\ns (baseline 80-90\ns) HR at 90-100\ns SR/ST while\n agitated up to 130\ns. RT leg edema. Pulses present. INR supratheraputic\n at 5.3. Will get another 1U pRBCs and 1L D5HCO3 for low urine output\n with BPs in 80s-90s. (Goal: Continue D5 Bicarb/blood boluses as needed\n for low urine output or systolic <85, or if symptomatic)\n GI: abd soft non tender, positive for BS. NPO for now poor MS.\n : amber color urine via foley minimal amnt 10-20cc/hr. bolus\n fluid/blood prn UOP\n Skin: multiple ecchymotic areas. : Platelets 68 on presentation.\n INR-5.3. c/o itching\n lotion applied and benadryl given\n w/positive effect.\n IV access: LT chest porthacath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Physician ", "chartdate": "2145-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370482, "text": "TITLE:\n Chief Complaint:\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n -RUQ u/s done- no read yet\n -Awaiting Dr to come see pt. If does need an LP would need to be\n done by neurosurg\n -Calcium repleated and free Ca was 1.15\n -Pt required Haldol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone 1g IV q24\n Vancomycin 1mg IV q48\n Infusions:\n Other ICU medications:\n Simvastatin 40 daily\n Folic acid\n Thiamine\n Senna\n Lactulose 30 \n Famotidine\n Haldol Prn\n Ibuprofen\n Tylenol\n hydroxyzine\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 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.3\nC (99.2\n HR: 77 (76 - 163) bpm\n BP: 130/35(56) {94/27(47) - 145/102(111)} mmHg\n RR: 13 (10 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,485 mL\n 67 mL\n PO:\n TF:\n IVF:\n 1,485 mL\n 67 mL\n Blood products:\n Total out:\n 1,353 mL\n 170 mL\n Urine:\n 1,353 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 132 mL\n -103 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n PE:\n Gen: alert, awake, cooperative, NAD, oriented to self , thought it was\n ^nd and asking how she got here\n Cardiac: rrr ns1/s2 no m/r/g\n Pulm: CTAB anteriorly\n ABD: +bs soft ntnd\n Extremities: right arm in flexion. 3- strength on right side. Left\n side grip . UE 4+/5 and LE plantarflexion 4+/5. DP pulses +1\n bilaterally and LE edema to above ankles +.\n Labs / Radiology\n 130 K/uL\n 9.6 g/dL\n 85 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 116 mEq/L\n 147 mEq/L\n 28.8 %\n 4.2 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n 04:06 AM\n WBC\n 4.5\n 4.7\n 5.8\n 4.2\n Hct\n 22.6\n 26.9\n 32.0\n 28.8\n Plt\n 68\n 67\n 106\n 130\n Cr\n 1.9\n 1.7\n 0.8\n 0.6\n Glucose\n 89\n 103\n 77\n 85\n Other labs: PT / PTT / INR:15.8/27.3/1.4, ALT / AST:32/58, Alk Phos / T\n Bili:103/0.9, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.2 g/dL, LDH:411 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.8\n mg/dL\n ASSESSMENT AND PLAN:\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status and feeling of\n weakness on left side. Has weakness on right side at baseline.\n .\n #. Altered Mental Status: Pt had AMS on admission and thru ,\n oriented only to self and was combative. On her mental status\n improved dramatically. Thought likely to be toxic/metabolic factors in\n the setting of old CVA deficits. The toxic/metabolic factors could\n include PNA, oxycodone use, and possible small contribution of\n hypocalcemia. There was concern for leptomeningeal disease given her\n metastatic breast cancer to the cerebellum, however, LP was not\n persueed given pt's mental status cleared and we would not expect it to\n resolve spontaneously. Seizure could also be responsible if AMS was\n secondary to seizure. CT of the head was negtive for CVA or TIA, bleed,\n or new edema. Pt still has innumerable calcified metastatic foci and\n mild edema. She refused MRI given her severe clostrophobia. Her\n oxycodone was discontinued and her calcium was repleated. Pt did\n receive antibiotics for bacterial meningitis in the ED but they were\n not continued given that she had no fever or signs of meningismus.\n -d/c lactulose (was given for concern for hepatic encephalopathy )\n -avoid narcotics, low dose inbuprofen and Tylenol for pain.\n .\n #. PNA: Left retrocardiac mild PNA.\n -continue ceftriaxone and vanco.\n -f/u final on blood cx still pending\n .\n # Increased LFTs: RUQ was done for concern of rising LFTs given pt has\n liver mets.\n -Some biliary sludge found on RUQ ultrasound.\n .\n #. Acute renal failure: Pt was pre-renal (FENA 0.1%) in setting of\n poor PO intake reported by family and continuation of home BP\n medications (ACE-I, lasix, and Coreg). Her baseline creatinine is 0.5.\n Her creatinine on admission was 2.3. Pt had received fluid boluses\n early on in the admission for hypotension.\n -creatinine today at 0.6\n .\n #. Hypotension: Pt was hypotensive on admission to 67 SBP and she\n received fluid boluses. Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50.\n -consider restarting BP meds tomorrow.\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She was day 18 of\n her gemcitabine therapy so this liekly represent marrow suppression\n from that cycle. (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia. Her coumadin was held. Her\n thrombocytonpenia improved to the 130s today.\n -continue to follow daily plts\n .\n #. Anemia: HCT since in 29-33 range. On presentation HCT was\n 23.5 and now is 32. Suspect large part of this may be marrow\n suppression secondary to chemotherapy, as has no signs of bleeding\n (guaiac negative in ED). Her hemolysis labs were negative. Poor\n reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively. She received one unit of\n blood while in the ICU and bumped appropriately. HCT stable at 28.8 on\n .\n -daily HCT check\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week prior to admission. Most\n likely secondary to oxycodone. She was treated with benedryl which was\n later discontinued due to her MS changes.\n -consider atarax prn puritis\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n She had no signs of cord compresion or cauda equina as rectal tone and\n sensation in tact. She was pain free on day of call out from ICU.\n -ibuprofen (low dose) or tylenol (low dose given liver fx) for pain\n control.\n .\n #SVT: Pt had 2 episodes of SVT while in the ICU with HR up to 150 which\n responded to metoprolol 5IV. No episodes of SVT on .\n .\n # Breast Cancer: Not active pt while an in patient.\n -tx plan per primary oncologist\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR. She was seen by nutrition and\n originally placed on a restriceted diet.\n -advanced diet to soft dysphagia\n -continue supplement with boost/ensure.\n .\n #. History of DVT: Patient's INR was supratherapeutic on admission.\n She had no signs of bleeding. Anticoagulation was held in anticipation\n of LP. Coumadin restarted on at 3mg daily down from home dose\n of 5mg daily given that she was supratherapeutic and also on\n antibiotics.\n .\n #. History of cardiomyopathy: Held ACE-I, lasix, and coreg in setting\n of hypotension.\n -consider restarting tomorrow.\n ICU Care\n Nutrition: soft dysphagia\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\n Prophylaxis:\n DVT: restarting coumadin today\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI, pressors ok\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2145-03-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 370485, "text": "Chief Complaint: Altered mental status\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 Improved mental status, less aggitated and beligerant.\n Cooperative, oriented.\n ULTRASOUND - At 03:13 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Vancomycin - 04:50 PM\n Ceftriaxone - 06:37 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:38 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: 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, 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\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:46 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.6\nC (99.6\n HR: 89 (76 - 117) bpm\n BP: 107/46(61) {94/27(47) - 150/102(111)} mmHg\n RR: 17 (10 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 1,485 mL\n 570 mL\n PO:\n 390 mL\n TF:\n IVF:\n 1,485 mL\n 180 mL\n Blood products:\n Total out:\n 1,353 mL\n 385 mL\n Urine:\n 1,353 mL\n 385 mL\n NG:\n Stool:\n Drains:\n Balance:\n 132 mL\n 185 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n 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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) 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: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, 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): Ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Right hemiparasis\n Labs / Radiology\n 9.6 g/dL\n 130 K/uL\n 85 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 116 mEq/L\n 147 mEq/L\n 28.8 %\n 4.2 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n 05:02 AM\n 04:06 AM\n WBC\n 4.5\n 4.7\n 5.8\n 4.2\n Hct\n 22.6\n 26.9\n 32.0\n 28.8\n Plt\n 68\n 67\n 106\n 130\n Cr\n 1.9\n 1.7\n 0.8\n 0.6\n Glucose\n 89\n 103\n 77\n 85\n Other labs: PT / PTT / INR:15.8/27.3/1.4, ALT / AST:32/58, Alk Phos / T\n Bili:103/0.9, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.2 g/dL, LDH:411 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n Altered mental status, delerium, confusion.\n ALTERED MENTAL STATUS, DELIRIUM -- Subactue onset. Attributed to\n toxic-metabolic dysfunction in setting of infection/sepsis, with\n possible contribution of medication effect (Levofloxicin, narcotics) on\n background of prior CVA. Also consider seizure with post-ictal or\n confusional state --> consider EEG.\n HYPOVOLEMIA (VOLUME DEPLETION -- improved. Monitor.\n HYPOCALCEMIA -- mild. Check ionized. Repleted.\n PRURITIS -- symptomatic treatment. Resolved.\n AGGITATION -- resolved.\n RENAL FAILURE -- acute, resolving with iv fluids. Monitor.\n MALIGNANCY -- extensive, widely metastatic.\n Possible INFECTION -- indwelling iv catheter --> line related\n infection. new LLL infiltrate --> Empirical antimicrobials.\n h/o DVT -- resume coumadin, monitor PT on coumadin.\n NUTRITIONAL SUPPORT -- resume PO under supervision. Consider formal\n speech/swallow evaluation if concern.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:35 PM\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 :Transfer to floor\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370356, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Pt agitated at AM refusing for monitoring vitals,labs and personal\n care,resisting for ICU level of care even after explaining,says\nplease\n \n me, \n it\n and MD was informed,husband called at\n Am and updated will be coming later to visit.\n Altered mental status (not Delirium)\n Assessment:\n Patient was agitated most of the night with periods of quiet time in\n between,oriented to self pulling at clothes and lines,speech is not\n clear,c/o pain on lower limbs continued to have low grade temps HR 150\n when pt was agitated Appears to be delirious and paranoid, Head CT\n from EW\n no acute bleed or stroke.\n Action:\n Continue lactulose for question of hepatic encephalopathy ( however at\n this time unable to give PO\ns poor mental status)NS 500 ml bloused\n and Metoprolol 5 mg/IV and Haldol 1 mg/Iv,Benadryl IV,Morphine IV given\n with effect.\n Response:\n Pt was in NSR after metoprolol ,Patient continued to be agitated and\n uncooperative while giving care\n Plan:\n Pt is DNR/DNI Continue to monitor patient\ns mental status, f/u Cx data\n and electrolytes, IVF hydration\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370371, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Pt tachy to 120s throughout day. Pt recieving 1u PRBC at the time,\n but was still tachy in 100s a couple hrs prior to getting blood. Pt\n denied pain, anxiety, no fevers, normal TSH, and only slightly dry MM -\n but good UOP and +balance nearly 2L - so did not give further fluids at\n the time (and was already getting blood). Came down on its own by 7pm\n - At 11:30pm pt became tachy to 150s - ?SVT. Pt agitated would not\n allow carotid massage, gave metop 5 IV x1, 500ml NS bolus, haldol 1mg\n x1, and pt 's HR returned to 90s.\n EKG - At 04:08 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:39 PM\n Morphine Sulfate - 06:46 PM\n Metoprolol - 11:23 PM\n Haloperidol (Haldol) - 11:23 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 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 139 (96 - 139) bpm\n BP: 147/83(96) {87/40(31) - 147/107(102)} mmHg\n RR: 16 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 815 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 815 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 550 mL\n Urine:\n 942 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\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 67 K/uL\n 9.2 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n WBC\n 4.5\n 4.7\n Hct\n 22.6\n 26.9\n Plt\n 68\n 67\n Cr\n 1.9\n 1.7\n Glucose\n 89\n 103\n Other labs: PT / PTT / INR:47.3/34.7/5.3, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Likely hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure, worsening LFT\n abnormalities and narcotics in setting of poor substrate and poor\n reserve leading to deficits as noted and exacerbation of old CVA\n deficits.\n Other likely contributors contributors:\n - toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure and worsening LFTs)\n - left lower lobe infiltrate, likely aspiration\n Les likely contributors:\n - CVA or TIA, (CT head prelim neg)\n - infection of indwelling port, urine (UA bland), CNS (no consistent\n symptoms)\n - seizures with post-ictal state in setting of brain metastases\n - intracranial hemorrhage/mass effect/edema (no evidence on CT scan)\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed.\n - Will continue to monitor and unless starts to bleed\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with oxycodone, tylenol\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370273, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n Transfused 1U pRBCs, Hct bumped from 22.6 to 26.9.\n Minimal urine output, increased to 20cc/hr after blood infusion. Giving\n 500cc bolus of D5HCO3\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 05:55 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: 36.6\nC (97.9\n HR: 87 (79 - 91) bpm\n BP: 98/77(83) {83/14(46) - 133/87(95)} mmHg\n RR: 13 (8 - 20) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,225 mL\n 640 mL\n PO:\n TF:\n IVF:\n 225 mL\n 290 mL\n Blood products:\n 350 mL\n Total out:\n 200 mL\n 72 mL\n Urine:\n 53 mL\n 72 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,025 mL\n 568 mL\n Physical Examination\n GENERAL: Elderly thin female, chronically ill, in NAD, but appearing\n somewhat confused.\n HEENT: NC/AT. No conjunctival pallor, PERRL, no scleral icterus. Mucous\n membranes slightly dry, slight asymmetry of nasolabial fold.\n NECK: Supple, flat JVP, no LAD appreciated. No meningismus, Kernig and\n Brudzinski signs negative\n CARDIAC: Regular, III/VI SEM best heard at LUSB, no rubs or gallops\n LUNGS: Clear to ascultation anteriorly and posteriorly with very\n occasional wheeze, few rales at bases\n ABDOMEN: Soft, NT, ND, +BS, no dullness to percussion, no guarding or\n rebound tenderness\n GU: Rectal tone WNL (as assessed by nursing), patient appearing\n uncomfortable when temperature obtained, no inguinal masses or\n tenderness to palpation\n EXTR: Warm, bilateral ecchymoses over tibias, right leg slightly more\n edematous than left. Some signs of venous stasis. Right arm fixed in\n contracted position. Few excoriations over arms. No clubbing, cyanosis,\n or trace to 1+ edema.\n NEURO: Alert, oriented to self, \" in \" but not to\n date. Squeezes eyes symmetrically, PERRL. Tongue mid-line. Grip on\n left, on right, upper extremity on left. Left leg 4-/5 (lifts\n off bed against gravity), plantar flexion left, right 3-/5. Toe\n down-going on left, up-going on right.\n Labs / Radiology\n 67 K/uL\n 7.4 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n WBC\n 5.5\n 4.5\n 4.7\n Hct\n 23.5\n 22.6\n 26.9\n Plt\n 68\n 68\n 67\n Cr\n 2.3\n 1.9\n 1.7\n Glucose\n 111\n 89\n 103\n Other labs: PT / PTT / INR:49.4/38.0/5.6, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L, Albumin:2.6\n g/dL, LDH:542 IU/L, Ca++:7.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL.\n Retic 0.5, Fibrinogen 373, Iron 39, TIBC 164, Folate, Ferritin, B12 >\n assay, TSH 3.1\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Differential includes CVA or TIA,\n toxic/metabolic secondary to electrolyte disturbances (in setting of\n acute renal failure) or infection (potential sources include lung with\n possible aspiration given decreased mental status over last few days,\n indwelling port, urinary infection, CNS though story is less convincing\n for this), seizures with post-ictal state in setting of brain\n metastases, intracranial hemorrhage. Suspect that some degree is likely\n from poor perfusion in setting of hypovolemia and hypotension. Recent\n use of oxycodone could also be contributing to depressed mental status.\n To pull together the story, suspect this is a case of hypoperfusion and\n toxic/metabolic encephalopathy due to renal failure and narcotics in\n setting of poor substrate and poor reserve leading to deficits as noted\n and exacerbation of old CVA deficits.\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes\n - Renal failure management as discussed below\n - Consider neurology consult in AM if mental status not improved with\n above interventions, would also consider additional imaging such as MRI\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction.. In setting of thromcytopenia, anemia,\n and altered mental status, TTP/HUS is also a possibility, but no\n schistocytes or rise in T. Bili.\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - Repeat peripheral smear in AM to again check for schistocytes\n - Urine eos neg\n - Currently making fairly good urine, will continue to monitor output\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue IVF boluses as needed for low urine output or systolic <85,\n or if symptomatic, however will use D5 with three amps of bicarb given\n metabolic acidosis (likely secondary to renal failure), and will need\n to be mindful of her cardiomyopathy.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Baseline prior to this appears to vary,\n likely secondary to cycles of chemotherapy (75-400's). TTP/HUS is\n consideration as noted above, but no schistocytes, T. Bili is normal,\n no fevers.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED). Will also rule out hemolysis by checking laboratories, however\n no schistocytes on smear noted.\n - Hemolysis labs\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - s/p transfusion of 1U with appropriate bump.\n - Iron, B12 and folate all nondeficient\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Differential includes\n secondary to uremia from renal dysfunction, medication effect (pruritis\n started around same time as she started oxycodone, and reported\n incidence of pruritis is up to 12-13%), worsening liver disease (she\n has known metastases).\n - Checking LFT's, renal failure management as noted above\n - Checking TSH, ferritin\n - Sarna PRN, holding off on benadryl or atarax as these may cloud\n assessment of mental status\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. Bilateral leg pain: Unclear etiology. Patient currently unable to\n give further details. In setting of possible urinary retention, cauda\n equina syndrome is a consideration, but patient currently without\n sensory deficits with normal rectal tone and discomfort with rectal\n thermometer. Response to oxycodone also is less consistent with cord\n compression. She has known bony metastases of her pelvis and spine, so\n these could also be causing pain (eg via nerve impingement or\n pathologic fracture)\n - Start with plain films to rule out compression fracture and/or\n pelvis/hip fracture\n - Consider further imaging of spine in AM if/once patient is more\n stable\n - Should she develop new deficits, would consider initiation of\n steroids for question of cord compression\n - Continue oxycodone for pain control\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed. Will continue to monitor and unless starts to bleed,\n wait for INR to trend downward.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 at 100 cc/hr overnight, bolus for hypotension,\n monitoring and repleting electrolytes aggressively. Sips until mental\n status improves.\n .\n #. Pain management with oxycodone, tylenol\n ICU Care\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370401, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n - Pt tachy to 120s throughout day. Pt recieving 1u PRBC at the time,\n but was still tachy in 100s a couple hrs prior to getting blood. Pt\n denied pain or anxiety. She had no fevers, a normal TSH, and only\n slightly dry MM. She had good UOP and +balance nearly 2L - so did not\n give further fluids at the time. In addition the patient was already\n getting blood. HR came down on its own by 7pm\n - At 11:30pm pt became tachy to 150s - ?SVT. Pt agitated would not\n allow carotid massage, gave metop 5 IV x1, 500ml NS bolus, haldol 1mg\n x1, and pt 's HR returned to 90s.\n -Early in AM pt given benadry and morphine for itching and agitation.\n -HR to 150s at 7am. Gave metoprolol 5 IV x1 and HR decreased to 90s.\n EKG unchanged from prior schowing SVT.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone 1g IV q24\n Vancomycin 1mg IV q48\n Infusions:\n Other ICU medications:\n Simvastatin 40 daily\n Folic acid\n Thiamine\n Senna\n Lactulose 30 \n Famotidine\n Haldol Prn\n Ibuprofen\n Tylenol\n hydroxyzine\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: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 139 (96 - 139) bpm\n BP: 147/83(96) {87/40(31) - 147/107(102)} mmHg\n RR: 16 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 815 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 815 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 550 mL\n Urine:\n 942 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination:\n General: agitated, following basic commands, slurred speech, oreinted\n to self, oriented to location (said but stated that was an\n accident and knows she is at . Later was able to say again she is at\n ). Knows name of her husband. Thought it was .\n HEENT: Dry mmm, no icterus\n CV: RRR ns1/s2 no m/r/g\n Lungs: CTAB anteriorly and posteriorly\n Abd: soft, NTND, no HSM, no RUQ tenderness\n Peripheral Vascular: Right radial pulse: 1+, left radial pulse: 1+,\n Right DP pulse: 1+, Left DP pulse: 1+\n Skin: No rashes\n Extremities: R arm in flexion. Unable to squeeze right hand or step on\n gas pedal with R foot. Pt states both of these are chronic. Grip and\n plantar flexion intact on left.\n Labs / Radiology\n 106K/uL\n 10.8 g/dL\n 77 mg/dL\n 0.8 mg/dL\n 25mEq/L\n 4 mEq/L\n 20 mg/dL\n 112 mEq/L\n 143 mEq/L\n 32 %\n 5.8 K/uL\n [image002.jpg] Ca 7.7 mg 2 ph 3 pt 15.6 ptt 29.3 inr 1.8\n 08:16 PM\n 05:37 AM\n WBC\n 4.5\n 4.7\n Hct\n 22.6\n 26.9\n Plt\n 68\n 67\n Cr\n 1.9\n 1.7\n Glucose\n 89\n 103\n Other labs: PT / PTT / INR:47.3/34.7/5.3, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Ddx includes infection (likely\n LLL infiltrate), hypocalcemia, leptomeningeal spread of breast CA,\n hypoperfusion, toxic/metabolic encephalopathy (pt was in renal\n failure), narcotics, seizure secondary to brain mets. Could be\n contributing to exacerbation of old CVA deficits.\n -CT of the head negtive for CVA or TIA, bleed, or new edema. Pt still\n has innumerable calcified metastatic foci and mild edema.\n Plan:\n -Hypocalcemia: repleated Ca2+\n - Will discuss with Dr. the possibility of leptomeningeal dz and\n whether LP and cytology would help. Unable to get MRI given pt has\n severe clostrophobia. Holding ibuprofen and coumadin given possibility\n of LP.\n -Bacterial meningitis in ddx but no meningeal sign/fever: pt already on\n ceftriaxone and vancomycin for PNA. If concern for meningitis\n increases would start ampicillin.\n -Infection: LLL infiltrate likely. Continue ceftriaxone and vanco.\n f/u blood cx still pending, urine cx negative\n -Goal MAP >55-60\n - Continue lactulose for question of hepatic encephalopathy\n -Haldol prn for agitation\n -Avoid narcotics and benadryl as much as possible\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal\n (fena 0.1%) in setting of poor PO intake reported by family and\n continuation of home BP medications (ACE-I, lasix, and Coreg). Her\n baseline creatinine is 0.5. Trend of creatinine 2.3 -> 1.9 -> 1.7 ->\n 0.8.\n -continue to trend creatinine\n .\n #PNA: continue cetriaxone and vancomycin.\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. Today pt normotensive (required fluid bolus earlier in\n admission).\n .\n #Increased LFTs\n -RUQ u/s today\n -follow LFTs\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 19 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: HCT since in 29-33 range. On presentation HCT was\n 23.5 and now is 32. Suspect large part of this may be marrow\n suppression secondary to chemotherapy, as has no signs of bleeding\n (guaiac negative in ED). s/p transfusion of 1U with appropriate bump.\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n -.\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and atorax prn.\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with low doses of tylenol or ibuprofen.\n .\n #SVT:\n -metoprolol 5mg IV Prn for HR >120\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n .\n #. History of DVT: Patient's INR was supratherapeutic and now\n subtherapeutic. No current signs of bleeding or history of bleeding.\n - Holding coumadin given possibility of LP, type and cross sent in\n event she needs to be urgently reversed.\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with low doses of tylenol (given LFTs) and low doses\n ibuprofen (given kidney fx).\n ICU Care\n Nutrition:\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2145-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370396, "text": "74 year old female with past medical history of metastatic breast\n cancer, DVT on coumadin, prior CVA and cardiomyopathy, who presents\n with altered mental status.\n Altered mental status (not Delirium)\n Assessment:\n This morning patent is agitated, confused, paranoid and hostile. Head\n Ct from EW\n no acute bleed or stroke. Patient refuses MRI.\n Action:\n Morphine/ benadryl given w/positive effect. Continue lactulose for\n question of hepatic encephalopathy (however at this time unable to give\n PO\ns poor mental status and questionable aspiration). Haldol added,\n levofloxacin changed to ceftriaxone, benadryl changed to atarax.\n Response:\n 1-2 hr later patient appears to be calm, comfortable, follows commands\n and converses w/medical staff and family members. However still\n frequent episodes of agitation/hostility and inappropriate behavior.\n Plan:\n Continue to monitor patient\ns mental status, f/u Cx data and\n electrolytes, IVF hydration\n Resp: on RA w/sats at 100%. Bil LS clear, RRR, unlabored breathing.\n Cardio: B/P 110-130\ns (baseline 80-90\ns) HR at 80\n-100\ns SR/ST while\n agitated up to 130\n 150\ns SVT. RT leg edema. Pulses present. This am\n Hr up to 160\ns SVT/ST. ECG done. Lopressor 5mg given w/positive effect\n (down to 80\n GI: abd soft non tender, positive for BS. No BM this shift. Senna added\n to bowel regimen. NPO for now poor MS. S&S eval\n mild dysphasia\nground diet w/nectar thick liquids until MS improves.\n GU: amber color urine via Foley about 30-40cc/hr\n Skin: multiple ecchymotic areas. C/o itching\n lotion applied and\n benadryl given w/positive effect. Benadryl switched to atarax to\n prevent over sedation.\n IV access: LT chest porthacath\n this am does not draw or flush easily.\n IV nurse re-accessed and redressed the cath.\n Social: patient is a DNR/DNI. Family in to visit updated by RN/MD.\n" }, { "category": "Physician ", "chartdate": "2145-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370395, "text": "TITLE:\n Chief Complaint: Ms. is a 74 year old female with past\n medical history of metastatic breast cancer, DVT on coumadin, prior CVA\n and cardiomyopathy, who presents with altered mental status.\n 24 Hour Events:\n - Pt tachy to 120s throughout day. Pt recieving 1u PRBC at the time,\n but was still tachy in 100s a couple hrs prior to getting blood. Pt\n denied pain or anxiety. She had no fevers, a normal TSH, and only\n slightly dry MM. She had good UOP and +balance nearly 2L - so did not\n give further fluids at the time. In addition the patient was already\n getting blood. HR came down on its own by 7pm\n - At 11:30pm pt became tachy to 150s - ?SVT. Pt agitated would not\n allow carotid massage, gave metop 5 IV x1, 500ml NS bolus, haldol 1mg\n x1, and pt 's HR returned to 90s.\n -Early in AM pt given benadry and morphine for itching and agitation.\n -HR to 150s at 7am. Gave metoprolol 5 IV x1 and HR decreased to 90s.\n EKG unchanged from prior schowing SVT.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 06:10 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:39 PM\n Morphine Sulfate - 06:46 PM\n Metoprolol - 11:23 PM\n Haloperidol (Haldol) - 11:23 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 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 139 (96 - 139) bpm\n BP: 147/83(96) {87/40(31) - 147/107(102)} mmHg\n RR: 16 (10 - 30) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 62 Inch\n Total In:\n 3,773 mL\n 815 mL\n PO:\n TF:\n IVF:\n 3,073 mL\n 815 mL\n Blood products:\n 700 mL\n Total out:\n 942 mL\n 550 mL\n Urine:\n 942 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,831 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination:\n General: agitated, following basic commands, slurred speech, oreinted\n to self, oriented to location (said but stated that was an\n accident and knows she is at . Later was able to say again she is at\n ). Knows name of her husband. Thought it was .\n HEENT: Dry mmm, no icterus\n CV: RRR ns1/s2 no m/r/g\n Lungs: CTAB anteriorly and posteriorly\n Abd: soft, NTND, no HSM, no RUQ tenderness\n Peripheral Vascular: Right radial pulse: 1+, left radial pulse: 1+,\n Right DP pulse: 1+, Left DP pulse: 1+\n Skin: No rashes\n Extremities: R arm in flexion. Unable to squeeze right hand or step on\n gas pedal with R foot. Pt states both of these are chronic. Grip and\n plantar flexion intact on left.\n Labs / Radiology\n 67 K/uL\n 9.2 g/dL\n 103 mg/dL\n 1.7 mg/dL\n 20 mEq/L\n 4.6 mEq/L\n 28 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.9 %\n 4.7 K/uL\n [image002.jpg]\n 08:16 PM\n 05:37 AM\n WBC\n 4.5\n 4.7\n Hct\n 22.6\n 26.9\n Plt\n 68\n 67\n Cr\n 1.9\n 1.7\n Glucose\n 89\n 103\n Other labs: PT / PTT / INR:47.3/34.7/5.3, ALT / AST:50/82, Alk Phos / T\n Bili:124/0.4, Differential-Neuts:77.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:15.0 %, Eos:2.0 %, Fibrinogen:373 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:542 IU/L, Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n Ms. is a 74 year old female with past medical history of\n metastatic breast cancer, DVT on coumadin, prior CVA and\n cardiomyopathy, who presents with altered mental status.\n .\n #. Altered Mental Status, weakness: Ddx includes infection (likely\n LLL infiltrate), hypocalcemia, leptomeningeal spread of breast CA,\n hypoperfusion, toxic/metabolic encephalopathy (pt was in renal\n failure), narcotics, seizure secondary to brain mets. Could be\n contributing to exacerbation of old CVA deficits.\n -CT of the head negtive for CVA or TIA, bleed, or new edema.\n Plan:\n - Will hold antibiotics for bacterial meningitis (already received\n vancomycin, ceftriaxone, and ampicillin), given no true signs of\n meningmus on exam, no fevers, and history no really consistent with\n this, after further discussion with husband as noted above.\n - Follow up culture data (blood, sputum if possible, urine)\n - Follow up electrolytes in setting of acute renal failure\n - Follow up final head CT read, consider repeat imaging in next day or\n days to assess for evolving process.\n - Support blood pressure as needed with IVF and pressors if needed for\n MAP >55-60\n - No LP given elevated INR, thrombocytopenia, husband\ns wishes for no\n invasive procedures\n - Renal failure management as discussed below\n - Continue lactulose for question of hepatic encephalopathy (waiting\n for LFTs to return, has history of liver involvement of metastases)\n - Touch base with Dr or covering neuro oncologist\n - transfuse another unit pRBCs to HCT >30\n .\n #. Acute renal failure: Given elevated BUN, could be all pre-renal in\n setting of poor PO intake reported by family and continuation of home\n BP medications (ACE-I, lasix, and Coreg). Her baseline creatinine is\n 0.5. Given lack of urination, post-obstructive etiology is also a\n possibility although she has no known metastates in the pelvis that\n would account for obstruction..\n - FeNa 0.1%, Una 12, Uosm 329\n - Will consider checking renal ultrasound in AM if not improving after\n hydration\n - No schistocytes on multiple smears to suspect TTPHUS\n - Urine eos neg\n - bolus fluid/blood prn UOP\n .\n #. Hypotension: Per hematology/oncology clinic notes, patient's\n baseline blood pressure over the last several weeks was recorded as\n 80-90/50. It has improved after receiving three liters of IVF to\n systolic currently 100-130's. No reason to be adrenal metastases known,\n but will consider stim should she remain hypotensive. Does not\n appear to be sepsis but checking cultures. Also may have low baseline\n in setting of cardiomyopathy. In the ICU has gotten 1U pRBCs and 50cc\n D5HCO3 for low urine output with BPs in 80s-90s.\n - Continue D5 bicarb/blood boluses as needed for low urine output or\n systolic <85, or if symptomatic. EF most recently 50% and satting 100%\n allowing for aggressive fluid resuscitation.\n - Should she develop signs of fluid overload, will need to initiate\n pressor support\n .\n #. Thrombocytopenia: Platelets 68 on presentation. She is day 18 of her\n gemcitabine therapy, so this could represent marrow suppression from\n that cycle (WBC could be disporportionally up secondary to\n administration of GSC-F). Consistent with severity and timing of prior\n post chemo thrombocytopenia.\n - Holding anti-platelet agents in setting of low count, no SQ heparin.\n - Monitor for signs of bleeding, transfuse should count be <20K or have\n symptoms\n .\n #. Anemia: Patient's last HCT was 29, with values since in\n 29-33 range. Today presentation HCT was 23.5, which is likely\n hemoconcentrated. Suspect large part of this may be marrow suppression\n secondary to chemotherapy, as has no signs of bleeding (guaiac negative\n in ED).\n - Hemolysis labs neg\n - poor reticulocytosis and anemia of chronic disease to account for\n macrocytosis and microcytosis respectively.\n - Iron, B12 and folate all nondeficient\n - s/p transfusion of 1U with appropriate , repeat today to\n goal 30\n .\n #. Pruritis: Per husband, and as noted on skin examination, this has\n been a major complaint over the last week. Most likely effect of\n oxycodone (timing consistent and common). Less likely uremia as\n pruritis persists after improved renal function, and bilirubin normal.\n TSH and ferritin also normal.\n - Sarna and benadryl prn (taken without worsened MS)\n .\n #. Bilateral leg pain: Likely due to compression by known spinal mets.\n No sign of cord compresion or cauda equina as rectal tone and sensation\n in tact.\n - Unclear use of imaging given no plan for procedures.\n - Symptomatic treatment with morphine IV prn, avoid oxycodone due to\n pruritis\n - Will consider LENI for DVT in AM once stable (already therapeutic on\n coumadin though, and swelling is more on leg affected by stroke)\n .\n #. Breast Cancer: Per discussion with husband, further treatment will\n be with different , however at this time, no active treatment\n while inpatient.\n - Will further discuss management with primary oncology team in the AM\n .\n #. Failure to thrive: Per OMR notes and discussion with husband, she\n has lost a significant amount of weight (>20 pounds) over the last\n several months, and has very poor PO intake. A trial of megace had been\n initiated, however this was stopped due to interaction with her\n coumadin and supratherapeutic INR.\n - Nutrition consult placed, NPO for now\n - Will need to further discuss this with husband and primary oncology\n team\n .\n #. History of DVT: Patient's INR is supratherapeutic. No current signs\n of bleeding or history of bleeding. Suspect given poor PO intake, lack\n of vitamin K in diet may be contributing to elevated INR.\n Administration of antibiotics may further increase INR.\n - Holding coumadin, type and cross sent in event she needs to be\n urgently reversed.\n - Will continue to monitor and unless starts to bleed\n .\n #. History of cardiomyopathy: Holding ACE-I, lasix, and coreg in\n setting of hypotension. Will carefully monitor IVF intake given\n depressed EF, however appears hypovolemic at present.\n .\n #. FEN: IVF, D5NAHCO3 maintenance while NPO\n .\n #. Pain management with oxycodone, tylenol\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Nutrition: Consult placed, PO diet once more stable.\n Glycemic Control: N/A\n Lines: Portacath (2 ports)\n Prophylaxis:\n DVT: supratherapeutic on coumadin, pneumoboot to left\n leg\n Stress ulcer: PPI\n Communication: Comments: Husband cell: \n Code status: DNR/DNI, Pressors okay. Per husband, no invasive\n procedures unless they would have palliative effect (eg palliative\n thoracentesis would be okay)\n Disposition:\n" }, { "category": "ECG", "chartdate": "2145-03-22 00:00:00.000", "description": "Report", "row_id": 130297, "text": "Sinus tachycardia. Left bundle-branch block. Low QRS voltage. Compared to\ntracing #2 the heart rate is faster.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2145-03-21 00:00:00.000", "description": "Report", "row_id": 130298, "text": "Sinus rhythm with low amplitude P waves. A-V conduction delay. Left\nbundle-branch block. Generalized low QRS voltage. Compared to tracing #1\nthe heart rate is slightly slower.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-03-21 00:00:00.000", "description": "Report", "row_id": 130299, "text": "Sinus tachycardia. Left bundle-branch block. Generalized low QRS voltage.\nCompared to the previous tracing of sinus tachycardia is now present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-03-20 00:00:00.000", "description": "Report", "row_id": 130300, "text": "Sinus rhythm. Left bundle-branch block. Low QRS voltage in the limb leads.\nCompared to the previous tracing of there is decreased QRS voltage in\nthe limb leads. The ventricular premature beat is absent.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1070213, "text": " 12:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed or CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with breast CA known brain mets, DVT on coumadin, prior CVA\n with R sided deficit, now with AMS and weakness\n REASON FOR THIS EXAMINATION:\n eval for bleed or CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb SAT 2:59 PM\n No acute hemorrhage. No change in innumerable calcified foci, c/w mets.\n Lesion in left cerebellum with mild associated edema is unchanged with no new\n mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old with breast cancer and known brain mets, on Coumadin\n with prior CVA and right-sided deficit. Now with altered mental status and\n weakness.\n\n COMPARISON: , , and .\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage. Innumerable\n coarse calcified foci throughout the cerebral and cerebellar hemispheres are\n consistent with the patient's treated brain metastases and are unchanged from\n multiple priors. The left cerebellar lesion, which showed mild contrast\n enhancement on prior exam and mild associated edema, is unchanged with no new\n mass effect. Hyperdense more discrete-appearing nodule in the left occipital\n lobe measures 10 mm and is also unchanged from . The ventricles\n and sulci are prominent consistent with age-related involutional changes.\n There are extensive calcifications within the carotid siphons. The lenses are\n absent. There are no lytic or sclerotic lesions. Moderate opacification of\n the mastoid air cells is again noted.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage.\n\n 2. No change in innumerable calcified metastatic foci and mild edema\n associated with the left cerebellar lesion. No new mass effect.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1070214, "text": " 1:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with metastatic breast CA and weakness\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old woman with metastatic breast cancer presenting with\n weakness.\n\n COMPARISON: Multiple prior exams, the most recent dated .\n\n AP UPRIGHT CHEST: A left subclavian catheter terminates in the right atrium.\n Mild cardiomegaly is stable. Left retrocardiac opacity and minimal bilateral\n interstitial prominence are similar to . Moderate left and small\n right pleural effusions are noted. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Left lower lobe opacity may represent pneumonia or edema. Recommend repeat\n imaging after diuresis to excluded underlying infection.\n\n 2. Minimal CHF.\n\n 3. Moderate left and small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-24 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1070895, "text": " 2:10 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG SWELLING - E/O DVT\n Admitting Diagnosis: ACUTE RESPIRATORY FAILURE/\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with RLE swelling and hx DVT.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old with right lower extremity swelling and history of\n prior DVT.\n\n No prior examinations.\n\n RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler examination of\n the right common femoral, superficial femoral and popliteal veins were\n performed and demonstrate normal compressibility, augmentability, and\n respiratory variation in flow. No intraluminal thrombus was identified. Of\n note, the veins are small in appearance which may relate to the prior DVT.\n\n IMPRESSION: No deep venous thrombosis within the right lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-22 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1070512, "text": " 2:12 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: RUQ PAIN, CHOLECSTITIS?\n Admitting Diagnosis: ACUTE RESPIRATORY FAILURE/\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with RUQ pain and delerium\n REASON FOR THIS EXAMINATION:\n Cholecystitis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old with right upper quadrant pain and delirium.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: There is limited evaluation of the liver,\n which appears mildly echogenic. No focal hepatic lesions are seen. The\n gallbladder is distended with sludge layering within it; however, there is no\n gallbladder wall edema or pericholecystic fluid. No son \n sign. The common duct measures 7 mm. The portal vein is patent with\n antegrade flow. There is no ascites. The spleen is not enlarged, measuring 8\n cm.\n\n IMPRESSION:\n 1. Slidghtly distended sludge-filled gallbladder, with other no evidence for\n acute cholecystitis. Clinical follow-up is recommended and if there is\n continued concern for acute cholecystitis, nuclear medicine hepatobiliary\n scan can be performed.\n\n 2. Limited evaluation of the liver, however, likely echogenic liver\n suggestive of fatty infiltration or fibrosis/cirrhosis.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-23 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1070786, "text": " 9:28 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: any evidence of stroke or blood vessel damage (pt h/o radiat\n Admitting Diagnosis: ACUTE RESPIRATORY FAILURE/\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman p/w MS changes and ? of progressive weakness on right side\n and l sided weakness.\n REASON FOR THIS EXAMINATION:\n any evidence of stroke or blood vessel damage (pt h/o radiation)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp WED 2:47 AM\n Pending recons: appearance to prior w/dystropic calc mets\n Ho'plastic L vert art but patent CoW GWlms\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 74-year-old woman with metastatic breast cancer who presents with\n mental status change and question of progressive weakness on the right side\n and left-sided weakness. Evaluate for stroke or blood vessel damage. The\n patient has a history of radiation.\n\n COMPARISON: Non-contrast head CT dated , and cervical spine CT\n dated are available for correlation.\n\n TECHNIQUE: Following a non-contrast head CT, axial multidetector CT images of\n the head and neck were obtained during intravenous contrast administration\n according to CTA protocol. Multiplanar two-dimensional reformatted images and\n volume-rendered three-dimensional reformatted images were generated.\n\n NONCONTRAST HEAD CT: There is no acute intracranial hemorrhage, edema, mass\n effect, or other CT signs of an acute major vascular territorial infarction.\n Multiple intracranial calcifications are unchanged compared to ,\n consistent with treated metastases. There is moderate cerebral atrophy with\n associated prominence of the sulci and ventricles, as before. Scattered\n hypodensities in the supratentorial white matter may be related to history of\n previous radiation therapy or sequela of small vessel ischemic disease.\n\n Partial opacification of mastoid air cells is present bilaterally, similar to\n .\n\n CTA NECK: There is calcified plaque at the origins of the innominate and left\n subclavian arteries, without evidence of hemodynamically significant stenoses.\n\n The distal common carotid and proximal internal carotid arteries are\n medialized. There is no evidence of stenoses or other abnormalities in the\n common carotid and cervical internal carotid arteries. The distal cervical\n right internal carotid artery measures 4.4 mm in diameter, and the distal\n cervical left internal carotid artery measures 3.8 mm in diameter.\n\n The left vertebral artery is hypoplastic. The right vertebral artery appears\n normal throughout its cervical course.\n (Over)\n\n 9:28 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: any evidence of stroke or blood vessel damage (pt h/o radiat\n Admitting Diagnosis: ACUTE RESPIRATORY FAILURE/\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n There are patchy opacities in the imaged apical portions of the upper lobes.\n Bilateral pleural effusions are partially visualized.\n\n There are multiple sclerotic lesions throughout the cervical and imaged upper\n thoracic spine, grossly unchanged compared to the cervical spine CT dated\n . Sclerotic lesions are also seen in the imaged upper\n sternum, some of which were not included in the field of view of the previous\n cervical spine CT.\n\n Multilevel spondylosis is again seen in the cervical spine.\n\n HEAD CTA: There is no evidence of hemodynamically significant stenoses or\n aneurysms in the intracranial circulation.\n\n IMPRESSION:\n\n 1. No evidence of stenoses in the cervical or intracranial arteries. No\n evidence of intracranial aneurysms.\n\n 2. No CT signs of an acute infarction. MRI would be more sensitive for an\n acute infarction.\n\n 3. Unchanged intracranial calcifications, consistent with treated metastases.\n\n 4. Unchanged sclerotic bone lesions in the spine. Sclerotic lesions in the\n sternum, not previously imaged. These are consistent with metastases.\n\n 5. Patchy pulmonary opacities in the imaged upper lungs. Partially imaged\n pleural effusions. Clinical correlation is recommended. Further evaluation\n may be performed by dedicated chest imaging.\n\n 6. Unchanged partial opacification of the mastoid air cells bilaterally.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2179-10-14 00:00:00.000", "description": "Report", "row_id": 1541925, "text": "7p to 7a Micu Progress Note\n\nNeuro - Alert and oriented x 3, difficulty with speech secondary to hx of CVA. Follows commands. MAE.\n\nResp - Lungs CTA. Sats > 97% on 2 L NC. RR 17-24.\n\nC-V - HR 70-80 SR with occas PAC's and PVC's. EKG in ER with L bundle (old), no ST changes. Cardiac enzymes being cycled. Pt denies CP or SOB. No edema. + palp peripheral pulses.\n\nGI - Abd soft. +BS. NPO except meds. Pt underwent endoscopy on previous shift which showed 2 7-10 cm ulcers found in the lower third of the esophagus and erythema in the fundus consistant with gastritis. Pt passed sm amt black melantoic ob + stool x 1. No vomiting. Denies abd pain.\n\nHeme/F/E - Hct 27.2 last eve. Pt being transfused 2 more units PRBCS. Hct drawn immed after 1st unit was 30.8. Needs repeat hct drawn 2 hrs after second unit is completed. Goal hct> 30. PT 17.5 PTT 31 INR 2.0. Pt given 40 mg lasix ivp in between units. Diuresed ~ 1 liter over the next 2 hrs. IV d51/2 NS infusing at 100ccs/hr but held during transfusion. Urine output 120-240ccs/hr via foley catheter. BUN 77 Cr 1.1 K 4.2.\n\nID - + VRE urine, contact precautions. Pt treated with one dose of ampicillin and one dose of gentamycin s/p endoscopy given hx of valve. Afeb. WBC 13.7.\n\nProphylaxis - Pneumo boots applied. Protonix administered.\n\nSkin - Chronic R heel decub. Wet to dry dssg applied. Son requests vascular be consulted and waffle boot be applied.\n\nEndo - RISS\n\nAccess - 2 peripheral #18 angios.\n\nSocial - Son visited last eve. Updated on pts condition. States he and other brother are both actively involved in decision making regarding pts plan of care.\n\nA+P - Continue to montior for GIB and CHF. Hct check q4 hrs. Transfuse to keep hct> 30.\n" }, { "category": "Nursing/other", "chartdate": "2179-10-14 00:00:00.000", "description": "Report", "row_id": 1541926, "text": "nursing note 7a-7p\nNEURO-alert,oriented x 2,oob for 2hr,general weakness.no c/o pain.\n\nRESP-on nc at 1l,no sob,sat-99%,bs cl ;dm to lb,no cough.\n\nCV-sr 70-80's,occ.pvc's,got 2gm mag.sulf ivpb,bp-130-140's,no edema,no c/o cp,last at 1600 35.2-stable.started on heparine gtt at 10am first ptt after 6 hr 46,gtt at 800u/hr.next ptt at 2200 with Hct & chem 7\n\nGI-abd soft,bs + x 4,no bm,no active bleed,no c/o pain,no n/v,full liq.diet tol.well.\n\nGU-foley,urine cl.&yellow\n\nSKIN-r foot ulcer,drs.&i,leg eleveted on the pillow.\n\nENDO -bs achs,RISS\n\nID-max temp 98.6,\n\nSOCIAL-son at bs,up dated per dr.\n" }, { "category": "Nursing/other", "chartdate": "2179-10-15 00:00:00.000", "description": "Report", "row_id": 1541927, "text": "7p to 7a Micu Progress Note\n\nNeuro - Remains alert and oriented x 2 to 3. MAE. Cooperative with care. Slept most of the noc.\n\nResp - LS clear. RR 17-23. 02 sats > 94%. Pt wearing 02 2l NC. Persistant dry cough.\n\nC-V - HR 70-86 SR with occas PACS and PVCs. Heparin drip dcd as INR 3.6. Given 3 mg coumadin po.\n\nGI - Abd soft. +BS. Sm smear black stool on sheet. Tolerating full liquid diet well. Hct stable at 34.3.\n\nID - Afeb. WBC 10.2. Being treated with levaquin for uti.\n\nF/E - TFB neg ~ 2 liters. Voiding 80-140ccs/hr via foley cath. Urine yellow with sed.\n\nSkin - Wet to dry dssg to heel decub. Waffle boot applied to RLE. L peripheral iv site infiltrated - Mod amt swelling and discomfort - pack applied with some relief.\n\nA+P - Pt\"s clinical status and hcts remain stable. ? call - out to floor. Nsg transfer note initiated.\n" }, { "category": "Nursing/other", "chartdate": "2179-10-15 00:00:00.000", "description": "Report", "row_id": 1541928, "text": "nursing note\npt. to be transfer to cc7,stable,no s&s of active bleed,no c/o pain,oob for 4hr.diet tol. well.social-son aware of transfer cc-719.\n" }, { "category": "Radiology", "chartdate": "2179-10-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804395, "text": " 3:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, CHF; on arrival to ICU\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with UGI bleed.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, CHF; on arrival to ICU\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Upper GI bleed.\n\n CHEST X-RAY, PORTABLE AP: The heart and mediastinal contours are\n unremarkable. A nasogastric tube is visualized, which passes out of sight\n below the level of the diaphragm. There is elevation of the right\n hemidiaphragm, of uncertain etiology. There are no infiltrates and there is\n no evidence of congestive heart failure. The patient is status post median\n sternotomy.\n\n IMPRESSION:\n\n 1) No evidence of congestive heart failure.\n\n 2) Elevation of the right hemidiaphragm, of uncertain etiology. Recommend\n correlation with prior films.\n\n" }, { "category": "ECG", "chartdate": "2179-10-13 00:00:00.000", "description": "Report", "row_id": 123750, "text": "Sinus rhythm with 1st degree A-V block.\nIV conduction defect suggest left bundle branch block\nPoor R wave progression - probable due to intraventricular conduction delay\nLateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nNo previous tracing\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2146-05-14 00:00:00.000", "description": "Report", "row_id": 1314564, "text": "nursing note 1900hrs - 0300hrs\n\n\nReturned from IR @ approx 21.30hrs post insertion of 17 coils around aneurysm of left optical nerve\n\n\nneuro - intially upon returning difficult to assess neuro status as still quite sleepy from anaesthetic ,only able @ this point to say name not orientated to time/place team aware - improved over the next hour and has remained stable - A/O x3 power/movement in all 4 limbs symmetrical smile,pupils equal/reactive to light denies any visual field defect denies any headaches - only c/o lower back discomfort as sheath remained insitu in rt fem artery overnight and therefore has remained flat - repostioned/ analgesia given for discomfort with some effect\n\n\ncvs - aim < 150 systolic, 115-150 maintained overnight, no nipride required for control - h/r 60-80 bpm - k @ 3.3 upon return supplemented in iv fluids running @ 120/hr - heparin commenced at 800u/hr at 2300hrs as requested by team as sheath remained insitu and increased to 900u/hr at 12mn post PTT , guided by team as no parameters set, for re-check @ 0400hrs - afebrile, hct stable @ 31\n\n\nresp - intially on face mask reduced to nasal prongs - lungs sound clear sats >97% - encouraged to cough/deep breath\n\n\ng/i - bowel sounds present - taken sips of clear fluids/ tollerated\n\ng/u - urine output satisfactory - foley now insitu - urine clear\n\nlines - rt radial art patent x2 peripheral - rt femeral sheath transduced for waveform/ insertion sight satisfactory no bleeding/oozing no haematoma present ?? for line removal this am, pedal pulses present\n\nskin - rt fem insertion sight as above, pressure araes intact, uncomfortable overnight due to postion\n\nsocial - team spoke with wife post procedure\n\nplan - for sheath removal from rt fem - continue with neuro checks\n" }, { "category": "Nursing/other", "chartdate": "2146-05-14 00:00:00.000", "description": "Report", "row_id": 1314565, "text": "Nursing Note:0700-\n\nDX:Cerebral Aneurysm\n\nShift Event: From the beginning of shift, Noted change in pt's personality & behavior. He was more impatient, snippity/agitated, occasionally (x2-3) talked in incomplete sentences & demanding. No neurological changes noted. MRI performed & a small infarct noted near corpus collosum. Restarted heparin.\n\nNeuro: Throughout the day, pt's neurological assessment was normal stable & unchanged. PEARL 3+, brisk. MAE upon command & ad lib with no strength deficeit noted in any extremeties. Speech clear, coherent & articulate. Only at start of shift was there any indication (ie word find difficulty [out for in] & incomplete sentence of any neuro change. The most significant change noted was the personality & bechavior change of pt (as stated above). The neuro- team was immediately notified of the change. They advised to continue to monitor. By noon time, the personality & behavior were very evident Both wife & daughter had spoken to RN noting the change while talking to him over the phone. Continued to advise neuro physician . of change & then it was decided to send pt for MRI. Results showed a small infarct. Heparin restarted at 800units/hr with pt/ptt level to be drawn at midnight. Neuro VS Q2h.\n\nInteg: Warm, dry, & intact. Rt area had no swelling or bruising at insertion site of sheath. Pt continues to keep Rt leg straight & remains flat.\n\nPain: In early am, c/o back aching. One percocet was given with the back ache resolving. Then at 5pm another percocet was given when pt stated his back was beginning to ache.\n\nCV: SR with no ectopic beats. HR:60's-70's. VSS with BP:130's-150's/ 60's-70's. At 11, HR spiked with BP d/t increase in agitation. A-line in Lt radial correlated well with NIBP. Both peripheral IV asymptomatic. NS with 20mEq KCL@120cc/hr thr LH IV. Antihypertensive med given as prescribed.\n\nPul: Lungs clear of adventitious breath sounds. RR even regular & unlaboured. Sating 95-99% on RA. No coughing noted.\n\nGI/GU: Abd soft non-tender with BS +ve in all quadrants. Tolerating diet well. No N/V or BM. Foley patent & draining good amts (>100cc/h) of clear urine.\n\nSocial: Daughter, & wife phoned several times talking to both pt & RN. They were kept well informed of pt's status.\n\nPlan: Continue neurological moritoring for changes. Any concerns are to be addressed with Dr. . Monitor coags. Next labs to be drawn at midnight. Provide pt with emotional when possible.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-05-15 00:00:00.000", "description": "Report", "row_id": 1314566, "text": "nursing note 1900hrs - 03.30hrs\n\n\nneuro - neuro exam appeared to have deteriorated A/O x2 - appeared to have difficulty formulating/expressing and slow to articulate words and hold a conversation - continiued to have full power in limbs obey commands denied headache or any visual field deficit - neuro team informed CT performed, no definitive result and symptoms persisted plus headache on left side started therefore MRI scan also done - reviewed and no further deteriration seen - team liased with DR - heparin re- commenced at 0300hrs for check ptt @ 0900hrs and stat dose of asprin given - ?? symptoms related to sleep deprivation/ alcohol withdrawl - reviewed by DR @ 03.30hrs - continue present treatment with heparin/ observation - presently continues as above with language/speech impediment but continiues full power limbs pupils equal reactive light/ obeys commnds A/O x2\n\n\ncvs b/p 140-160 systolic - liased with team re rising b/p acceptable to 165 systolic before starting nipride - when not stimulated b/p < 150 - h/r stable - all bloods checked last pm stable - iv fluids continue - t max @ 100 no cultures ordered/ to observe\n\n\nresp - chest clear sats>95% on room air - encouraged to cough/ deep breath\n\ng/i - npo at present - iv fluids continue\n\ng/u urine output satisfactory/ clear\n\nskin - pressure areas intact\n\nlines - art line patent - rt femeral sheath remains insitu and transduced - no haematoma oozing evident pedal pulses present\n\nsocial - wife/ daughter informed re latest scans /results\n" }, { "category": "Nursing/other", "chartdate": "2146-05-13 00:00:00.000", "description": "Report", "row_id": 1314562, "text": "nursing note - admitted for close observation of neuro /cvs prior to placement of coil in anuerysm found in left optic nerve [ left ACA ANEURYSM] - if coil unsuccessful to have clipping of surgery ? saturday\n\n\nneuro - alert/ orientated x3 moving all 4 limbs - power in all 4 limbs - following commands purpuseful movements, symmetrical smile - pupils equal/reactive to light, some blurred vision of right eye [ as symptoms prior to admission] but no worsening of - c/o left sided headache on admission [ as symptoms prior to admission] settled with x2 percocets - neuro team aware of vision/ headache\n\n\ncvs aim <140 systolic - maintained 100-130 systolic, intially had nitropaste on chest post angio as b/p > 140 but settled therefore paste removed - nipride perscribed if required - h/r 65-75 bpm sinus no ectopics - afebrile - iv fluids run @ 125cc/hr\n\ng/i - allowed light diet yesterday but post percocet and food small vomit - nil since - team informed - now npo for procedure today, fluids in progress as above\n\ng/u passed urine x2, intially with difficulty then when allowed of bed rest able to pass\n\nskin - right angio puncture sight satisafctory no bruise evident, able to sit up as of 11pm - other pressure aresa intact\n\nsocila - spoke with wife yesterday - team also updated her - she will visit this am prior to next procedure\n" }, { "category": "Nursing/other", "chartdate": "2146-05-13 00:00:00.000", "description": "Report", "row_id": 1314563, "text": "Nursing Note: 0700-1900\n\nShift Event: At 3pm, pt was take down to OR for placement of coils in aneurysm found behind left optic nerve. Pt not anticipate until after 9pm tonight.\n\nNeuro: AAOx3. MAE purposefully on own & upon command with no strength deficeits in any extremity. PEARL 3+ve & concentric. Optic nerves III, IV & VI appear to be intact. Vision continues to be blurred. Speech clear & coherent with no evidence of any facial anomilies.\n\nPain: C/O ongoing aching headache inspite of the percocet he had received (). MSO4 ordered & pt received 2mg IVx2. Stated that pain level decreased to post MSO4 administration.\n\nCV: NSR No ectopics. HR:64-74. NIBP:127-158/64-80. Goal to keep SBP<140 with the range of 110-130. Pt's SBP increased briefly to 177 d/t anxiety. Nipride was recommended if SBP remained >140 for more than 10mins. No pedal edemal. PPP.\n\nPul: Lungs field clear of adventious breath sounds. Sating >94% on RA. RR:. Breathing unlaboured, regular & even\n\nGI: NPO except for meds. No complaints of N/V.\n\nGU: Voiding on own standing up clear yellow urine (x4). Total 525cc for 8hr shift.\n\nInteg: Warm, dry & intact. Rt angio puncture site appear to be intact with minimal bruising evident. Small yellow faded bruise noted on Lt side of chin from dental surgery performed several days ago.\n\nSocial: Wife, & brother-in-law came in at 10:30 & left as pt was take to neuro angiography.\n" }, { "category": "Nursing/other", "chartdate": "2146-05-15 00:00:00.000", "description": "Report", "row_id": 1314567, "text": "Nursing Nurse: 0700-1900\n\nShift Event: Neurologically pt stable. Dr. called several time in am then he decide to take pt for an angiogram. Pt left at 1500. Results pending from proceedure. Addendum to follow once results known\n\nNeuro: No changes in pt's neurological status (all within normal limits). Family feels that he is conversing with them. Assessed pt is a little hesitant with his words & keeping his sentences brief. Noted only slight word finding difficulties. According to the neuro team, this may be d/t sleep depravation & slight DTs. Notes some slight hand tremors. Very restless in early am. Ativan 0.5mg IV x2 given. Pt slept for about 2.0hrs.\n\nInteg: Warm dry pale & intact. Rt femoral sheath still in place & transduced (waveform sharp). No hematoma, swelling, or oozing from site. Pulses palpable in the Rt leg. Rt leg remains straight\n\nPain: Pt denies pain when asked. No headaches only discomfort in back d/t lying flat in bed.\n\nCV: VSS (Refer to carevue for specific data). A-line has a good wave form & correlates within 10pt of NIBP. Afebrile. Peripheral IV asymptomatic. Banana bag hung & infusing at 125cc/hr thru Lt peripheral IV & heparing infusing @10cc/hr (1000units/hr). Ptt level at 09:45 was 37.4 & heparing rate was increased from 800u/hr to 1000u/hr. According to Dr. , the decision to keep the heparin infusing will depend on the results of the angiogram.\n\nResp: Lungs clear of adventitious BS. Breath even, regular & unlaboured. Sating 96-99% on RA.\n\nGI: BS +ve in all quadrants. Tolerated breakfast well & became NPO at 10am. No N/V or BM. He is passing flatus. Foley patent & draing >140cc/hr. of clear urine.\n\nSocial: Several family members in to visit with pt. All waiting in waiting room for end of proceedure.\n\nPlan: Pending results of angiogram, neuro monitoring should continue as they have been. Dr. believes that heparin will probable be stopped & the femoral sheath will be pulled late Monday afternoon then pt should be called out to the floor.\n" }, { "category": "Nursing/other", "chartdate": "2146-05-16 00:00:00.000", "description": "Report", "row_id": 1314568, "text": "nursing note 1900hrs -0300hrs\n\n\nRETURNED AT 1900HRS POST FURTHER X4 COILS INSERTED AROUND ACA ANEURYSM - TOTAL OF 21 COILS INSITU\n\n\nNEURO - received patient neuro observations inconsistent, unable to hold conservation, appears to have difficulty formulating words/ expressing words and words used garbled/confused, orientated to person inconsistent to time/place, inconsistent in naming objects, family memebers - team informed and reviewed several times - patient also agitated/figity/restless, small dose of ativan perscribed /given with some affect - patient continued to have full power of limbs following commands pupils equal reactive light\nteam reviwed - ?post procedure state due to a numder of factors - evolving embolic event post initial coil insertion on saturday, post anaesthetic this coil insertion, alcohol withdrawl and sleep deprivation\nobservations slightly improved over the course of the night - A/O x3 more consistent with naming objects/ family members, periodically restless/ agitated but less so than previous still unable to hold conversation\nheparin in progress as ordered - aim 60-70 ptt - recheck sent @ 3am await results continue close neuro obs\n\n\ncvs - aim < 160 systolic maintained , intially on nitro post procedure but weaned, range 140-160 overnight - h/r 60-70 bpm no ectopics - bloods checked post procedure stable k replaced in iv fluids, hct stable - T ,max @ 102 ? also contributing to neuro state , pan cultered cxr performed, atasol given temp gradually reduced no antibiotics perscribed as of yet\n\n\nresp - lungs sound clear sats 94-97% 2l via nasal cannula - RR 10-20\n\ng/i - taken sips of water/tollertated, no bowel motion\n\ng/u - good clear urine output via foley\n\nskin - remains in flat postion due to having sheath insitu in right groin- repositioned, pressure areas intact\n\n\nlines - left art line patent - sheath in rt fem transduced,insertion sight clean/dry no haematoma present, pedal pulses present ?? for removal of today\n\n\nsocial - wife called yesterday aware of presnt condition\n" }, { "category": "Nursing/other", "chartdate": "2146-05-16 00:00:00.000", "description": "Report", "row_id": 1314569, "text": "Nursing Progress Note MICU A\n\nNeuro: Alert and oriented x3. PEARL, 3mm/bsk. Follow all commands, strengths equal. Restless at times, ativan 0.5mg given with good effect. Wants to get OOB but has to lay flat post sheath removal. C/O back pain, tylenol 650mg given with good effect.\n\nCV: NSR with no ectopy noted. HR 63-76. SABP 129-171. Nitro gtt on at 0.8mcg/kg/min. Goal for SBP to be <160. IVF NS w/ 20KCL @ 120cc/hr. Right groin sheath pulled at 1100. Pt flat in bed 6 hours post sheath removal. No hematoma at site, no oozing. OOB at 1830 to chair without difficulty. +palp pedal pulses, no edema. Tmax 99.8.\n\nResp: LS clear upper airway and coarse in bases. O2 sat 93-98% on RA. Encouraged to C/DB.\n\nGI: Abd soft, non-tender, +bs, -bm. Tolerating low sodium diet without difficulty.\n\nGU: Foley cath intact with clear yellow urine. UO good.\n\nInteg: Right groin site with small dsd. C/D/I.\n\nSocial: Wife and daughter called and updated on pts progress.\n" }, { "category": "Nursing/other", "chartdate": "2146-05-17 00:00:00.000", "description": "Report", "row_id": 1314570, "text": "MICU-NPN\n\nNEURO: Initially continued with Q1 hr. neuro checks then Q2 hr's as MD orders. A&O to person/place/time except he did not know the name of this hospital. Speech clear, equal strengths in all 4 extremities, PERRL, 3mm, sluggish. Ativan 0.5mg given x2 for agitaion\n\nCV: Tmax: 99.6 po, HR 50's-70's SB/NSR no ectopy noted. SBP 120's-170's continues on Nitro gtt to keep SBP <160. Right groin dsg (old sheath site) D&I, no drng noted. +CSM, +PP.\n\nRESP: LS clear to coarse, Sat's as low as 90% on RA while asleep and 96-99% on 2LNC.\n\nGI/GU: Adequate UOP >100cc/hr via foley cath.\n" }, { "category": "Nursing/other", "chartdate": "2146-05-17 00:00:00.000", "description": "Report", "row_id": 1314571, "text": "Addendum:\n\nPt. is febrile to 101.1po, Dr. aware and does not want cultures at this time. No tylenol given MD. Phos. 1.5, awaiting repletion orders.\n" }, { "category": "Radiology", "chartdate": "2146-05-15 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 821826, "text": " 2:17 PM\n CAROT/CEREB Clip # \n Reason: S/P COILING/NEUROLOGICAL CHANGES\n Admitting Diagnosis: ANEURYSM\n Contrast: OPTIRAY Amt: 300\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Previously coiled left anterior cerebral artery\n aneurysm with presumed occlusion of the left anterior cerebral artery A1\n segment, now with speech hesitation, possible TIAs.\n\n POSTOPERATIVE DIAGNOSIS: Persistent small amount of flow past the coil mass in\n the left A1 segment requiring additional coil embolization with hydrocoil at\n the neck of the aneurysm to induce complete occlusion of the left A1 segment.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. is a patient who underwent coil embolization of the\n left A1 segment of the anterior cerebral artery. Postoperatively the patient\n did well but was noted to possibly have suffered and small embolic event in\n the territory of the left anterior cerebral artery. It is unclear whether this\n occurred as a result of coiling at the time of the procedure or whether it was\n the result persistent flow past the coil mass in delayed fashion. Subsequent\n MR angiography revealed persistent tiny amount of flow into the left A1\n segment anterior cerebral artery. Accordingly the decision was made to return\n the patient back to Angiography in order to determine the presence or absence\n of flow through the left anterior cerebral artery. If there is flow then\n decision will be made to proceed with additional coiling in order to\n permanently shut down the flow and decrease the chance of any emboli being\n carried to segmented left anterior cerebral artery territory.\n\n CONSENT: The patient and his wife were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n pateint and his wife understood and wished to proceed with the operation.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept\n (Over)\n\n 2:17 PM\n CAROT/CEREB Clip # \n Reason: S/P COILING/NEUROLOGICAL CHANGES\n Admitting Diagnosis: ANEURYSM\n Contrast: OPTIRAY Amt: 300\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: left common carotid artery,\n left internal carotid artery, left anterior cerebral artery A1 segment, left\n anterior cerebral artery aneurysm neck region, right common carotid artery,\n right internal carotid artery.\n\n RESULTS: After placement of the diagnostic catheter into the left common\n carotid artery angiographic run revealed no evidence of stenosis or dissection\n or significant change compared to prior. Injection of the left internal\n carotid artery revealed the previously coiled aneurysm and showed very slight\n opacification of the A2 segment anterior cerebral artery signifying that the\n neck of the aneurysm was not completely occluded. Accordingly decision was\n made to proceed with additional coiling of the region of the neck and with the\n intent of complete occlusion of the left A1 segment of the anterior cerebral\n artery. To that end a guidecatheter was placed into the left internal carotid\n artery. Through the guidecatheter a microcatheter was used to selectively\n catheterize the left A1 segment of the anterior cerebral artery in the neck\n region of the aneurysm. At this point additional coils were placed of\n hydrocoil variant. These coils were deployed into the neck of the aneurysm\n and also into the distal portion of the left A1 segment. Great care was taken\n to insure that the coil would not go beyond the neck of the aneurysm into the\n ACOM segment. Angiographic run at this point revealed complete occlusion of\n the left A1 segment flow with stasis. At this point the microcatheter was\n withdrawn and the diagnostic catheter was then used to selectively catheterize\n the right common carotid artery followed by the right internal carotid artery.\n The injection of the right common carotid artery showed unchanged appearance\n compared to prior with no evidence of stenosis or dissection. Injection of the\n right internal carotid artery with three-dimensional rotational angiography\n showed a persistent patent flow of the anterior communicating artery with\n perfusion of the bilateral anterior cerebral artery to segments and anterior\n cerebral artery territories. At this point the diagnostic catheter was removed\n and the patient was transferred back to intensive care in stable condition.\n Ever so slight but persistent flow past the coil mass in the left A1 segment\n of the anterior cerebral artery treated using additional GDC coil embolization\n and hydrocoil embolization of the neck of the aneurysm as well as the proximal\n portion of the left A1 segment in order to induce complete stasis and\n compensatory flow from the right A1 segment anterior cerebral artery via a\n patent anterior communicating artery.\n\n\n\n\n\n\n\n (Over)\n\n 2:17 PM\n CAROT/CEREB Clip # \n Reason: S/P COILING/NEUROLOGICAL CHANGES\n Admitting Diagnosis: ANEURYSM\n Contrast: OPTIRAY Amt: 300\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2146-05-14 00:00:00.000", "description": "MR-ANGIO HEAD", "row_id": 821778, "text": " 3:22 PM\n MR-ANGIO HEAD; MR HEAD W/O CONTRAST Clip # \n Reason: acute stroke; concern for left ACA distribution s/p aneurism\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with ACA left aneurism coil; now with personality changes, mild\n cognitive problems\n REASON FOR THIS EXAMINATION:\n acute stroke; concern for left ACA distribution s/p aneurism coil\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Patient with status post coiling of anterior communicating\n artery aneurysm with personality changes, r/o stroke.\n\n MRI OF THE BRAIN, MRA OF THE HEAD:\n\n TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion axial images\n of the brain were obtained. 3D time of flight MRA of the Circle of was\n acquired.\n\n FINDINGS:\n\n BRAIN MRI: There is a small area of restricted diffusion seen adjacent to the\n anterior of the left lateral ventricle in the region of corpus callosum\n consistent with a small acute infarct in the distribution of the left anterior\n cerebral artery. Artifacts from coiling of the large anterior communicating\n artery aneurysm are seen in the region of the cistern lamina terminalis.\n Additionally, small area of restricted diffusion is suspected in the left\n posterior frontal region, suspicious for a small acute infarct. A small area\n of susceptibility low signal is seen in the left frontal region on\n susceptibility weighted images in the left frontal region could be due to a\n small area of hemorrhage or thrombus in a middle cerebral artery cortical\n branch.\n\n There is no midline shift, mass effect or hydrocephalus seen.\n\n IMPRESSION: Status post coiling of the anterior communicating artery aneurysm.\n Small area of restricted diffusion in the left side of the corpus callosum\n indicate a small acute infarct in the distribution of anterior cerebral\n artery. A small second infarct is suspected in the left frontal cortical\n region. Other changes as above.\n\n MRA OF THE HEAD: The head MRA demonstrates normal flow signal in the posterior\n circulation and middle cerebral artery territories. There is no flow signal\n identified within the aneurysm. The right anterior cerebral artery A2 segment\n is well visualized. The distal portion of the A1 segment and the proximal\n portion of the A2 segment of the left anterior cerebral artery are not well\n seen and this could be due to artifacts from the adjacent coil mass.\n\n IMPRESSION: No evidence of residual flow signal seen within the aneurysm.\n Other changes as above.\n\n (Over)\n\n 3:22 PM\n MR-ANGIO HEAD; MR HEAD W/O CONTRAST Clip # \n Reason: acute stroke; concern for left ACA distribution s/p aneurism\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2146-05-12 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 821558, "text": " 9:50 AM\n CAROT/CEREB Clip # \n Reason: DAYCARE UNIT. START TIME 1:00. Diagnostic cerebral angiogr\n ICD9 code from order: 437.3\n Contrast: OPTIRAY Amt: 320\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with aneurysm.\n REASON FOR THIS EXAMINATION:\n DAYCARE UNIT. START TIME 1:00. Diagnostic cerebral angiogram.\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Left anterior cerebral artery possible aneurysm.\n\n POSTOPERATIVE DIGANOSIS: Wide-necked fusiform left anterior cerebral artery\n aneurysm of the A1 segment ending proximal to the anterior communicating\n complex wide-necked measuring approximately 15 mm at widest extent by 12 mm\n with a 5 mm neck.\n\n INDICATION: Mr. , has been complaining of visual difficulties\n and underwent an MRI of the brain which revealed the presence of a possible\n aneurysm in the anterior communicating region. He is undergoing this cerebral\n angiogram to better define location and the type of aneurysm to determine\n optimal therapy.\n\n CONSENT: The patient and his wife were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient and his wire understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: left common carotid artery,\n left internal artery, right common carotid artery, right internal carotid\n artery, with compression of the left internal carotid artery, right subclavian\n artery, right vertebral artery, left subclavian, left vertebral artery.\n\n (Over)\n\n 9:50 AM\n CAROT/CEREB Clip # \n Reason: DAYCARE UNIT. START TIME 1:00. Diagnostic cerebral angiogr\n ICD9 code from order: 437.3\n Contrast: OPTIRAY Amt: 320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n RESULTS: Injection of the bilateral common carotid arteries showed normal\n carotid bifurcations with no evidence of stenosis or injury. Injection of the\n right common carotid artery shows a tonsilar loop with an 180 degree turn.\n This is a normal variant. The injection of the left internal carotid artery\n with three-dimensional reconstruction shows the presence of a large aneurysm\n of the A1 segment of the anterior cerebral artery. It is inferiorly and\n posteriorly pointing and measures at its widest extent to 15 mm. In other\n dimensions it measures approximately 7 x 9 mm. Of note the inferior-posterior\n component is a daughter aneurysm and represents high risk for subsequent\n rupture. The aneurysm's neck is wide as shown by three-dimensional\n reconstruction and it ends proximal to the A1-2 junction. Injection of the\n right internal carotid artery with three-dimensional reconstruction showed no\n evidence of intracranial aneurysm. Injection of the right internal carotid\n artery with cross compression of the left internal carotid artery shows a\n patent anterior communicating artery. Injection of the bilateral subclavian\n arteries showed no evidence of stenosis or dissection and a normal origin of\n the bilateral vertebral arteries. Both vertebral arteries in the cervical\n region show significant tortuosity without significant atherosclerotic disease\n or stenosis. The proximal basilar region is tortuous. However there is no\n evidence of aneurysm of the posterior circulation. The bilateral posterior\n communicating arteries are patent. The venous phase is unremarkable. The\n bilateral external carotid arteries from the common injection are within\n normal limits with no evidence of abnormal arteriovenous shunting. Finally the\n three-dimensional construction of both internal carotid construction showed no\n evidence of other intracranial aneurysms that are visualizable at this point.\n\n IMPRESSION: Significant tortuosity of both internal carotid artery and\n vertebral artery in the cervical region and presence of a large aneurysm of\n the left A1 segment which is characterized by a daughter aneurysm and has a\n wide neck which ends proximal to the A1-2 junction on the left side.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-05-13 00:00:00.000", "description": "F/U TRANS CATH THERAPY", "row_id": 821663, "text": " 10:18 AM\n OTHER EMBO Clip # \n Reason: Pt will require coiling of left aca aneurysm\n Contrast: OPTIRAY Amt: 300\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with left aca aneurysm\n REASON FOR THIS EXAMINATION:\n Pt will require coiling of left aca aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Left A1 segment anterior cerebral artery aneurysm.\n\n POSTOPERATIVE DIAGNOSIS: Same. Status post endovascular coil embolization of\n the aneurysm using a combination of hydrogel and GDC coils\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. is a patient who presented with a symptomatic aneurysm\n of the left anterior cerebral artery which is also characterized by a daughter\n aneurysm. After discussion of his condition with his family, it was decided\n to proceed with endovascular coil embolization. A strategy of coiling the\n aneurysm followed by proximal occlusion of the left A1 segment was chosen\n given the presence of a patent and functional anterior communicating artery as\n demonstrated by the last angiogram.\n\n CONSENT: The patient and his wife were given a full and complete explanation\n of the procedure. Specifically the indications, risks, benefits and\n alternatives to the procedure were explained in detail. In addition the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient and his wife understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood, a 5 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Left common carotid artery, left internal carotid artery, left intracranial\n anterior cerebral artery and then left intracranial anterior cerebral artery\n aneurysm and then right common carotid artery, and then internal carotid\n artery. After placement of the guide catheter into the left common carotid\n artery, an angiographic run was performed which showed no evidence of\n (Over)\n\n 10:18 AM\n OTHER EMBO Clip # \n Reason: Pt will require coiling of left aca aneurysm\n Contrast: OPTIRAY Amt: 300\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dissection or stenosis in the cervical region. This was then used to\n selectively catheterize the left internal carotid artery. With the guide\n catheter in the left internal carotid artery, a Prowler plus microcatheter was\n used to catheterize the wide neck aneurysm of the left anterior cerebral\n artery. With the microcatheter in that position, a series of angiographic\n runs were obtained in between placement of GDC coils as well as hydrogel\n coated embolic coils. Intravenous angiography revealed progressive\n embolization of the aneuryms. At the end of the procedure, a final hydrocoil\n was placed. This was, however, noted to herniate out into the proximal left\n A1 segment and was best withdrawn. An angiographic run was then performed\n which showed that the aneurysm had been completely embolized and no\n significant flow was going pass the aneurysm into the anterior communicating\n artery. At this point, it was felt that the aneurysm was well embolized. At\n this point, the 4 FR diagnostic catheter was then used to selectively\n catheterize the right common carotid artery. This showed normal carotid\n bifurcation with no evidence of stenosis or dissection. Injection of the\n right internal carotid artery showed a patent anterior communicating artery.\n This also showed that the injection of the right internal carotid artery\n showed no evidence of vasospasm and showed that the right A1 segment of the\n anterior cerebral artery was not perfusing both distal anterior cerebral\n arteries. This is consistent with an occlusion of the left A1 at the level of\n the aneurysm neck.\n\n IMPRESSION: Left A1 segment of the anterior cerebral artery status post coil\n embolization using combination of hydrocoil and GDC coils with occlusion of\n the left A1 segment.\n\n" }, { "category": "Radiology", "chartdate": "2146-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821844, "text": " 10:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with ms change\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Mental status change, r/o pneumonia.\n\n PORTABLE AP CHEST: A single, AP semiupright image. No prior films are\n available for comparison. The heart is at the upper limits of normal in size.\n The pulmonary vessels show slight upper zone redistribution, consistent with\n the semi-upright posture of the patient. No pneumonic consolidation is\n identified. There is no evidence of any pleural effusion. The hilar and\n mediastinum are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary abnormality. In particular, there is no\n evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-05-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 821790, "text": " 9:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute bleed on heparin\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p left ACA aneurism coil, small left ACA infarct noted today,\n resumed heparin, now worsened language fluency\n REASON FOR THIS EXAMINATION:\n acute bleed on heparin\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post coiling of left ACA aneurysm with small left ACA\n infarct, now on heparin and worsened language fluency. Please evaluate for\n acute intracranial hemorrhage.\n\n COMPARISON: MR of the brain dated the same date.\n\n TECHNIQUE: Noncontrast head CT.\n\n CT OF THE HEAD WITHOUT INTRAVENOUS CONTRAST: Multiple metallic coils are seen\n at the skull base, with marked streak artifact limiting soft tissue detail.\n Just superior to this region, medial and inferior to the genu of the left\n internal capsule, there is a focus of ill-defined hyperdensity consistent with\n intraparenchymal hemorrhage. The ventricular size and configuration is\n unchanged. The ventricles are not dilated. There is no shift of normally\n midline structures or mass effect. No loss of -white differentiation is\n appreciated to correspond with the regions of restricted diffusion within the\n left frontal lobe and left corpus callosum noted on MR of the same date. A\n tiny focus of hypodensity within the posterior limb of the left internal\n capsule may represent an old lacunar infarct. The density values of the brain\n parenchyma are otherwise within normal limits. The basilar cisterns appear\n patent.\n\n BONE WINDOWS: Bone windows demonstrate no evidence of fracture. The mastoid\n air cells and visualized portions of the paranasal sinuses are normally\n pneumatized.\n\n Additional thin section reformats were obtained. The region of ill-defined\n hyperdensity superior to the coiling site, and medial and inferior to the genu\n of the left corpus callosum persists on thin section images and is consistent\n in appearance with an intraparenchymal hemorrhage.\n\n IMPRESSION:\n\n Prominent streak artifact arising from multiple metallic clips at the skull\n base limits visualization of the surrounding brain parenchyma. Allowing for\n this, a focus of hyperdensity medial and inferior to the genu of the left\n internal capsule. Differential considerations include artifactual vs\n intraparenchymal hemorrhage. No shift of normally midline structures or mass\n effect.\n (Over)\n\n 9:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute bleed on heparin\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-05-14 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 821791, "text": " 11:41 PM\n MR HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n MR-ANGIO HEAD; -77 BY DIFFERENT PHYSICIAN\n : ACA stroke today, worsened language on heparin, CT head obsc\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with ACA left aneurism coil, now with transcortical motor\n aphasia\n REASON FOR THIS EXAMINATION:\n ACA stroke today, worsened language on heparin, CT head obscured by artifact,\n concern for left anterior thalamic/fornix blood\n ______________________________________________________________________________\n FINAL REPORT\n MRA OF THE BRAIN AND MRA OF THE CIRCLE OF AT 23:45\n\n INDICATION: Left anterior cerebral artery aneurysm coiled with transcortical\n motor aphasia and anterior cerebral artery stroke today worsening language on\n Heparin evaluate for bleed in the thalamus and fornix.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted imaging of the brain was performed.\n Diffusion weighted scans are provided.\n\n 3D time-of-flight MR angiography of the circle of was performed.\n Multiplanar reformatted images and source image data are reviewed.\n\n Comparison is made to the previous CT scan of and the MRI and MRA of\n at 15:20\n\n FINDINGS\n\n FLAIR images demonstrate increased T2 signal posterior to the left anterior\n cerebral artery coiled aneurysm, involving the hypothalamus and medial\n temporal lobe. This is unchanged since the previous study and appears to be\n edema related to the aneurysm. There is no diffusion signal abnormality in\n this location. However, on diffusion weighted images there are patchy areas\n of increased signal in the left frontal lobe cortex, both anteriorly and\n medially, as well as within the deep white matter. This pattern is unchanged\n since the previous study and reflects infarction. There are also a few foci\n of increased diffusion signal in the right medial frontal cortex, also\n suspicious for infarction. There is no change in the appearance of the brain\n since the previous day. The ventricles are not enlarged.\n\n MRA of the circle of is unchanged since the previous examination. There\n continues to be flow signal identified in both anterior cerebral arteries, in\n the middle cerebral arteries, and within both internal carotid arteries, the\n basilar artery, intracranial vertebral arteries, superior cerebellar and\n posterior cerebral arteries. There is a segment of decreased flow signal in\n the left A1 arterial segment, which was also present on the previous study and\n is unchanged. This corresponds to decreased flow in this location of the\n recent angiogram.\n\n IMPRESSION: There is edema in the left hypothalamus and medial temporal lobe,\n (Over)\n\n 11:41 PM\n MR HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n MR-ANGIO HEAD; -77 BY DIFFERENT PHYSICIAN\n : ACA stroke today, worsened language on heparin, CT head obsc\n Admitting Diagnosis: ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adjacent to the coiled aneurysm. There are stable infarctions in the left\n frontal lobe, and perhaps the medial right frontal lobe. Overall, the\n appearance of the brain is unchanged since the previous examination.\n\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542182, "text": "AOx3, no gag, swallows without difficulty, takes pills with applesauce,\n team aware. +BS, LBM pre-op, HUO WNL, Off insulin gtt this am\n following protocol, {20 lantus, and 4 reg} Next BS 1500.\n Respiratory\n Assessment:\n History of smoking, extubated this am without difficulty, LS rhonchus,\n strong productive cough with thin whitish sputum, left apical pnuemo\n with 1 pleural and 2 mediastinal CT\n Action:\n Required 40% with face tent, inhalers a/o, CPT, repositioning, IS to\n 750, lasix started, up into chair, separated chest tubes~ pleural chest\n tube to suction and mediastinal to WS\n Response:\n 2 liters NC 98%., diuresing >100 an hour, no respiratory distress\n Plan:\n Continue to monitor, goal 92-100%, aggressive pulmonary hygiene\n Coronary artery bypass graft (CABG)\n Assessment:\n POD 1, CABGx4 labile BP on neo this am, , SR with PAC/PVC occasional,\n 2A2V wires {with sense/capture}, +PP bilaterally, left foot slightly\n mottled, team aware\n Action:\n Aggressive fluid resuscitation, labs sent for electrolytes, K repleted\n Response:\n stable SBP 110-120\ns, off pressors, Ma off d/t inappropriate pacing\n Plan:\n Continue to monitor VS, continue with cardiac pathway\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542184, "text": "AOx3, no gag, swallows without difficulty, takes pills with applesauce,\n team aware. +BS, LBM pre-op, HUO WNL, Off insulin gtt this am\n following protocol, {20 lantus, and 4 reg} Next BS 1500.\n Respiratory\n Assessment:\n History of smoking, extubated this am without difficulty, LS rhonchus,\n strong productive cough with thin whitish sputum, left apical pnuemo\n with 1 pleural and 2 mediastinal CT\n Action:\n Required 40% with face tent, inhalers a/o, CPT, repositioning, IS to\n 750, lasix started, up into chair, separated chest tubes~ pleural chest\n tube to suction and mediastinal to WS\n Response:\n 2 liters NC 98%., diuresing >100 an hour, no respiratory distress\n Plan:\n Continue to monitor, goal 92-100%, aggressive pulmonary hygiene\n Coronary artery bypass graft (CABG)\n Assessment:\n POD 1, CABGx4, SR with PAC/PVC occasional, 2A2V wires {with\n sense/capture}, +PP bilaterally, left foot slightly mottled, team\n aware, Ma off d/t inappropriate pacing\n Action:\n Started with Carvedilol, Labs sent for electrolytes,\n Response:\n stable SBP 110-120\ns, off pressors, Transient bradycardia (58-60), , 20\n mEq K repleted, pacer back on A demand with rate of 30, ma 20 and \n .4\n Plan:\n Continue to monitor VS, continue with cardiac pathway\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542181, "text": "AOx3, no gag, swallows without difficulty, takes pills with applesauce,\n team aware. +BS, LBM pre-op, HUO WNL, Off insulin gtt this am\n following protocol, {20 lantus, and 4 reg} Next BS 1500.\n Respiratory\n Assessment:\n History of emphysema, extubated this am without difficulty, LS\n rhonchus, strong productive cough with thin whitish sputum\n Action:\n Required 40% with face tent, inhalers a/o\n Response:\n 2 liters NC 98%.\n Plan:\n Continue to monitor, goal 92-100%, aggressive pulmonary hygiene\n Coronary artery bypass graft (CABG)\n Assessment:\n POD 1, CABGx4 labile BP on neo this am, left apical pnuemo with pleural\n chest tube to suction and mediastinal to WS, SR with PAC/PVC\n occasional, 2A2V wires {with sense/capture}, +PP bilaterally, left foot\n slightly mottled, team aware\n Action:\n Aggressive fluid resuscitation, labs sent for electrolytes, K repleted\n Response:\n stable SBP 110-120\ns, off pressors, Ma off d/t inappropriate pacing\n Plan:\n Continue to monitor VS, continue with cardiac pathway\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542183, "text": "AOx3, no gag, swallows without difficulty, takes pills with applesauce,\n team aware. +BS, LBM pre-op, HUO WNL, Off insulin gtt this am\n following protocol, {20 lantus, and 4 reg} Next BS 1500.\n Respiratory\n Assessment:\n History of smoking, extubated this am without difficulty, LS rhonchus,\n strong productive cough with thin whitish sputum, left apical pnuemo\n with 1 pleural and 2 mediastinal CT\n Action:\n Required 40% with face tent, inhalers a/o, CPT, repositioning, IS to\n 750, lasix started, up into chair, separated chest tubes~ pleural chest\n tube to suction and mediastinal to WS\n Response:\n 2 liters NC 98%., diuresing >100 an hour, no respiratory distress\n Plan:\n Continue to monitor, goal 92-100%, aggressive pulmonary hygiene\n Coronary artery bypass graft (CABG)\n Assessment:\n POD 1, CABGx4, SR with PAC/PVC occasional, 2A2V wires {with\n sense/capture}, +PP bilaterally, left foot slightly mottled, team\n aware, Ma off d/t inappropriate pacing\n Action:\n Started with Carvedilol, Labs sent for electrolytes,\n Response:\n stable SBP 110-120\ns, off pressors, Transient bradycardia (58-60), , 20\n mEq K repleted, pacer back on A demand with rate of 30, ma 20 and \n .4\n Plan:\n Continue to monitor VS, continue with cardiac pathway\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542156, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n a-paced @ 70 for underlying SB @ 50 with decrease in Bp.\n Hemodynamically stable on levo.propofol,insulin gtts. Vented cpap/ps.\n Ls rhonchorous. Moaning & facial grimacing with activity. Adeq. u/o.\n CXR showed aleft apical pneumo.\n Action:\n Propofol weaned off. Pt awoke appropriately and followed all commands.\n ABG wnl.weaned to cpap 5/5 pt extubated without incidence to 40%\n aerosol coolmist mask. Impaired->absent gag. Coughing/raising Blood\n tinged thin sputum.morphine ivp for c/o incisonal pain.\n Response:\n Pt stable post extubation and on NO gtts. Painrelieved with morphine.\n Plan:\n Separate CT to independent CT . Continue to monitor all\n systems. De-line, increase activity and food intake. Transfer to 6\n later today.\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542149, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n a-paced @70 with underlying sb @ 50 with decrease in bp.\n Hemodynamically stable. Propofol & levo gtts dcd. Vent weaned. LS\n rhonchorous Adeq. u/o. incisional pain.\n Action:\n Awoke appropriately & followed all commands. Extubated to 40% aerosol\n mist mask. Ls rhonchorous. Sxd moderate amt OLD bloody secretions. CPT\n bilateral sides. Moderate cough.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2182-12-10 00:00:00.000", "description": "Intensivist Note", "row_id": 542151, "text": "CVICU\n HPI:\n 76M POD # 1 from CABG x4 (LIMA>LAD, SVG>DIAG, SVG>RAMUS, SVG>OM). EF\n 30-35%. Episode of severe hypotension overnight\n Chief complaint:\n PMHx:\n MI, HTN, Hyperlipidemia, diverticulosis s/p colon resection,\n degenerative disc dz, Lt eye blindness d/t occlusion of optical artery,\n Bladder CA s/p removal, s/p prostate surgery.\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:10 PM\n OR RECEIVED - At 04:32 PM\n EKG - At 04:40 PM\n URINE CULTURE - At 05:01 PM\n NASAL SWAB - At 05:01 PM\n ARTERIAL LINE - START 05:10 PM\n CORDIS/INTRODUCER - START 05:10 PM\n CCO PAC - START 05:11 PM\n Post operative day:\n 24 hr events:\n - Episode of hypotension (SBP in 70s), initially not responding to\n fluids. Finally improved with several liters of crystaloids and\n albumin. Mixed venous in the 80s throughout this event.\n - Extubated successfully\n - Milrinone weaned to off\n - Air leak in L CT. Small apical pneumothorax\n - Hyperglycemic on insulin gtt\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Vancomycin - 08:12 PM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:13 PM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 76 (65 - 93) bpm\n BP: 93/52(67) {70/37(50) - 153/86(100)} mmHg\n RR: 24 (12 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 15 (6 - 20) mmHg\n PAP: (51 mmHg) / (25 mmHg)\n CO/CI (Fick): (4.1 L/min) / (2.2 L/min/m2)\n CO/CI (CCO): (4.6 L/min) / (2.1 L/min/m2)\n SvO2: 66%\n Mixed Venous O2% sat: 75 - 86\n Total In:\n 6,648 mL\n 135 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,148 mL\n 135 mL\n Blood products:\n 500 mL\n Total out:\n 810 mL\n 890 mL\n Urine:\n 580 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,838 mL\n -755 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 477 (400 - 477) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.43/38/111/24/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : 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)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 174 K/uL\n 12.3 g/dL\n 125\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 109 mEq/L\n 136 mEq/L\n 35.0 %\n 12.0 K/uL\n [image002.jpg]\n 05:07 PM\n 06:46 PM\n 08:27 PM\n 08:35 PM\n 10:00 PM\n 02:00 AM\n 02:36 AM\n 02:51 AM\n 04:00 AM\n 05:00 AM\n WBC\n 12.0\n Hct\n 34.4\n 35.0\n Plt\n 174\n Creatinine\n 0.9\n TCO2\n 22\n 21\n 22\n 26\n Glucose\n 76\n 81\n 113\n 130\n 105\n 120\n 122\n 125\n Other labs: PT / PTT / INR:17.0/37.6/1.5, Fibrinogen:297 mg/dL, Lactic\n Acid:2.0 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 76M POD # 1 from CABG x4 (LIMA>LAD, SVG>DIAG,\n SVG>RAMUS, SVG>OM). EF 30-35%. Episode of severe hypotension overnight,\n resolved. Extubated successfully.\n Neurologic: Neuro checks Q: 4 hr, pain not well controlled w/ low dose\n morphine. will start percocets.\n Cardiovascular: Aspirin, Beta-blocker, Statins, acute on chronic\n systolic heart failure. bradycardic + hypotension overnight. corrected\n w/ pacing + fluid resuscitation. currently hemodynamically stable w/o\n pacing.\n Pulmonary: IS, chest pt. OOB to chair. continue CT due to high outputs.\n Gastrointestinal / Abdomen: no issues.\n Nutrition: Regular diet, Advance diet as tolerated , will advance diet.\n Renal: Foley, oliguric overnight. responded to fluid resuscitation.\n diuresis today.\n Hematology: Serial Hct, stable hct.\n Endocrine: RISS, glucose was well controlled on insulin drip, now DC'd.\n cont on RISS.\n Infectious Disease: periop vancomycin. afebrile. no e/o infection.\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Pacing wires,\n cont chest tubes.\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:10 PM\n Cordis/Introducer - 05:10 PM\n CCO PAC - 05:11 PM\n 18 Gauge - 05:11 PM\n Prophylaxis:\n DVT: (on pump CABG. no DVT prophylaxis indicated.)\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2182-12-10 00:00:00.000", "description": "ICU Note - CVI", "row_id": 542152, "text": "CVICU\n HPI:\n HD6\n POD 1\n 76M s/p CABG x4 (LIMA>LAD, SVG>DIAG, SVG>RAMUS, SVG>OM) \n EF 30-35% Wt 71 Cr 1.5\n PMH MI, HTN, Hyperlipidemia, diverticulosis s/p colon resection,\n degenerative disc dz, Lt eye blindness d/t occlusion of optical artery,\n Bladder CA s/p removal, s/p prostate surgery,\n ASA 81', labetolol 400\" (changed to coreg OSH), lisinopril 10',\n lipitor 40', HCTZ 25', proscar, prilosec, NTG SL prn, metamucil\n Current medications:\n Albuterol-Ipratropium, Albuterol MDI, Aspirin EC, Atorvastatin,\n Docusate Sodium, Finasteride, Furosemide, Insulin, Metoprolol\n Tartrate, Oxycodone-Acetaminophen, Pantoprazole\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:10 PM\n OR RECEIVED - At 04:32 PM\n EKG - At 04:40 PM\n URINE CULTURE - At 05:01 PM\n NASAL SWAB - At 05:01 PM\n ARTERIAL LINE - START 05:10 PM\n CORDIS/INTRODUCER - START 05:10 PM\n CCO PAC - START 05:11 PM\n Post operative day:\n POD 1\n s/p CABG x4 (LIMA>LAD, SVG>DIAG, SVG>RAMUS, SVG>OM)\n 24 hour events received from OR, hypotension treated with fluid and\n pressors, extubated\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Last dose of Antibiotics:\n Vancomycin - 08:12 PM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:13 PM\n Other medications:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 76 (65 - 93) bpm\n BP: 93/52(67) {70/37(50) - 153/86(100)} mmHg\n RR: 24 (12 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 15 (6 - 20) mmHg\n PAP: (51 mmHg) / (25 mmHg)\n CO/CI (Fick): (4.1 L/min) / (2.2 L/min/m2)\n CO/CI (CCO): (4.6 L/min) / (1.4 L/min/m2)\n SvO2: 66%\n Mixed Venous O2% sat: 75 - 86\n Total In:\n 6,648 mL\n 137 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,148 mL\n 137 mL\n Blood products:\n 500 mL\n Total out:\n 810 mL\n 890 mL\n Urine:\n 580 mL\n 640 mL\n NG:\n Stool:\n Drains:\n ct 230 mL\n ct 250 mL\n Balance:\n 5,838 mL\n -753 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 477 (400 - 477) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.43/38/111/24/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\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), left EVH\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 174 K/uL\n 12.3 g/dL\n 125\n 0.9 mg/dL\n 24 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 109 mEq/L\n 136 mEq/L\n 35.0 %\n 12.0 K/uL\n [image002.jpg]\n 05:07 PM\n 06:46 PM\n 08:27 PM\n 08:35 PM\n 10:00 PM\n 02:00 AM\n 02:36 AM\n 02:51 AM\n 04:00 AM\n 05:00 AM\n WBC\n 12.0\n Hct\n 34.4\n 35.0\n Plt\n 174\n Creatinine\n 0.9\n TCO2\n 22\n 21\n 22\n 26\n Glucose\n 76\n 81\n 113\n 130\n 105\n 120\n 122\n 125\n Other labs: PT / PTT / INR:17.0/37.6/1.5, Fibrinogen:297 mg/dL, Lactic\n Acid:2.0 mmol/L\n Imaging: CXR left apical ptx\n Microbiology: urine entercoccus tx with cipro - awaiting\n sensitives, repeat u/a neg\n urine cx pending\n MRSA pending\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, morphine prn -\n change to percocet prn\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, cough and deep breath, chest PT\n Gastrointestinal / Abdomen: no issues\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO, start lasix for diuresis\n Hematology: stable hct\n Endocrine: RISS, Insulin drip, Lantus (R)\n Infectious Disease: vancomycin for periop antibiotics, no indication of\n uti based on u/a follow up culture\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion,\n Lantus (R) protocol\n Lines:\n Arterial Line - 05:10 PM\n Cordis/Introducer - 05:10 PM\n CCO PAC - 05:11 PM\n 18 Gauge - 05:11 PM\n Prophylaxis:\n DVT:\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" }, { "category": "Respiratory ", "chartdate": "2182-12-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 542128, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n :\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: White / Thick\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 Comments: Pt was on vent support, switched on PSV o/n.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n :\n Plan\n Next 24-48 hours: Continue with daily tests & SBT's as tolerated;\n Comments: Pt done ~53.\n elective extubation this AM, on Cool mist FT.\n Reason for continuing current ventilatory support: None. EXTUBATED.\n" }, { "category": "Nursing", "chartdate": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542213, "text": "Patient POD #1 from cabg x4. unstable post op required\n meds/volume/albuminx1. exutabed this morning. Improved!!\n Patient a+ox3. no apparent deficit. Conversing/pleasant\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR with pacs/pvcs. Rate 70s-80s, but dropped transiently in afternoon\n after carvedilol to 56-60\n Action:\n Pacer ademand. K already repleted from previous shift.\n Response:\n Con\nt monitor. ? held pm carvedilol d/t hr.\n Plan:\n Respiratory\n Assessment:\n LS rhonchus, wheezes. Diminish bases. Maintain sat >97% on 2lnc.\n Breathing even. Congested cough raising sm-mod amt white secretion. Low\n grade temp. left side pleural rub noted- Left CT remain in to water\n seal now by NP \nno leak, serous drg.. CXR done in pm after\n MT chest tube \n by NP.\n Action:\n Aggressive pulm hygiene. Is/cbc/cpt. Oob to chair. Repositioning.\n Lasix. Mdi.\n Response:\n Patient able to raise secretion. Denies sob/dyspnea. Maintain sat >96%.\n Plan:\n Con\nt diuresis, pulm hygiene. Follow up with cxr. ?L ct status.\n Pain; Patient c/o sternal incisional pain. Medicate with 1 percocet prn\n with relief.\n Physical: patient weak required 2 assisted to get oob to chair. PT to\n eval patient tomorrow POD2\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 71 kg\n Daily weight:\n 84.5 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,diverticulitis,turp,lt. eye\n blindness from occluded optical artery(pupil dose react), pre op nics\n neg.,gerd,hx bladder ca s/p resection, present smoker \n cigars/day,mod. emphysema-cxr->peribronchiolar ground glass\n appearance,pft's->mod. obstructive disease. cath->mv disease,echo->ef\n 30-35%,lv systolic dysfuction w inf. & apical akinesis/dyskinesis.\n Surgery / Procedure and date: c x 4 lima->lad,diag,, pre\n T->mod-severe lv dysfunction with inf. & septal akinesis,apical\n akinesis/dsyskinesis.,ef ~ 30%,rv hypertrophied,pcwp ~ 18. post T->off\n on low dose milrinone,levo for bp support(bp unresponsive to neo)aorta\n noted to be calcified,complex mobile atheroma noted desc. thoracic\n aorta.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:54\n Temperature:\n 99.8\n Arterial BP:\n S:112\n D:45\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 61 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 40% %\n 24h total in:\n 488 mL\n 24h total out:\n 2,349 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 16 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 3.5 mA\n Temporary ventricular stimulation setting :\n 3 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 136 mEq/L\n 02:36 AM\n Potassium:\n 4.0 mEq/L\n 12:42 PM\n Chloride:\n 109 mEq/L\n 02:36 AM\n CO2:\n 24 mEq/L\n 02:36 AM\n BUN:\n 19 mg/dL\n 02:36 AM\n Creatinine:\n 0.9 mg/dL\n 02:36 AM\n Glucose:\n 78\n 09:00 AM\n Hematocrit:\n 35.0 %\n 02:36 AM\n Finger Stick Glucose:\n 124\n 12:00 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": "2182-12-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542215, "text": "Patient POD #1 from cabg x4. unstable post op required\n meds/volume/albuminx1. exutabed this morning. Improved!!\n Patient a+ox3. no apparent deficit. Conversing/pleasant\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR with pacs/pvcs. Rate 70s-80s, but dropped transiently in afternoon\n after carvedilol to 56-60\n Action:\n Pacer ademand. K already repleted from previous shift.\n Response:\n Con\nt monitor. ? held pm carvedilol d/t hr.\n Plan:\n Respiratory\n Assessment:\n LS rhonchus, wheezes. Diminish bases. Maintain sat >97% on 2lnc.\n Breathing even. Congested cough raising sm-mod amt white secretion. Low\n grade temp. left side pleural rub noted- Left CT remain in to water\n seal now by NP \nno leak, serous drg.. CXR done in pm after\n MT chest tube \n by NP.\n Action:\n Aggressive pulm hygiene. Is/cbc/cpt. Oob to chair. Repositioning.\n Lasix. Mdi.\n Response:\n Patient able to raise secretion. Denies sob/dyspnea. Maintain sat >96%.\n Plan:\n Con\nt diuresis, pulm hygiene. Follow up with cxr. ?L ct status.\n Pain; Patient c/o sternal incisional pain. Medicate with 1 percocet prn\n with relief.\n Physical: patient weak required 2 assisted to get oob to chair. PT to\n eval patient tomorrow POD2\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 71 kg\n Daily weight:\n 84.5 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Unspecified \n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,diverticulitis,turp,lt. eye\n blindness from occluded optical artery(pupil dose react), pre op nics\n neg.,gerd,hx bladder ca s/p resection, present smoker \n cigars/day,mod. emphysema-cxr->peribronchiolar ground glass\n appearance,pft's->mod. obstructive disease. cath->mv disease,echo->ef\n 30-35%,lv systolic dysfuction w inf. & apical akinesis/dyskinesis.\n Surgery / Procedure and date: c x 4 lima->lad,diag,, pre\n T->mod-severe lv dysfunction with inf. & septal akinesis,apical\n akinesis/dsyskinesis.,ef ~ 30%,rv hypertrophied,pcwp ~ 18. post T->off\n on low dose milrinone,levo for bp support(bp unresponsive to neo)aorta\n noted to be calcified,complex mobile atheroma noted desc. thoracic\n aorta.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:54\n Temperature:\n 99.8\n Arterial BP:\n S:112\n D:45\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 61 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 40% %\n 24h total in:\n 488 mL\n 24h total out:\n 2,349 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 16 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular sensitivity setting:\n 2 mV\n Temporary ventricular stimulation threshold :\n 3.5 mA\n Temporary ventricular stimulation setting :\n 3 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 136 mEq/L\n 02:36 AM\n Potassium:\n 4.0 mEq/L\n 12:42 PM\n Chloride:\n 109 mEq/L\n 02:36 AM\n CO2:\n 24 mEq/L\n 02:36 AM\n BUN:\n 19 mg/dL\n 02:36 AM\n Creatinine:\n 0.9 mg/dL\n 02:36 AM\n Glucose:\n 78\n 09:00 AM\n Hematocrit:\n 35.0 %\n 02:36 AM\n Finger Stick Glucose:\n 124\n 12:00 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": "2182-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542108, "text": "Unstable bp with episodes hypotension into the 70\ns unresponsive to\n volume,levo titration. Neo added,cacl2 pushed,milrinone dose decreased\n with improvement.svo2 & ci remain acceptable. Remains a paced for bp\n support,underlying rhythm nsr with occasional pac\ns & pvc\ns. bursts of\n svt. Lytes repleted with improvement.v wires reported to function intra\n op but not tested as yet due to hypokalemia,irritability. Breath sounds\n distant bilat,no wheezes. + intermittent air leak noted,peep decreased\n from 8->5.remains sedated on propofol,will attempt waking & vent\n weaning when criteria are met.\n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542109, "text": "Unstable bp with episodes hypotension into the 70\ns unresponsive to\n volume,levo titration. Neo added,cacl2 pushed,milrinone dose decreased\n with improvement.svo2 & ci remain acceptable. Remains a paced for bp\n support,underlying rhythm nsr with occasional pac\ns & pvc\ns. bursts of\n svt. Lytes repleted with improvement.v wires reported to function intra\n op but not tested as yet due to hypokalemia,irritability. Breath sounds\n distant bilat,no wheezes. + intermittent air leak noted,peep decreased\n from 8->5.remains sedated on propofol,will attempt waking & vent\n weaning when criteria are met.\n ------ Protected Section ------\n Continues to require volume for labile bp,low filling pressures &\n unchanged hct. Air leak very intermittent after peep change. Expiratory\n wheezes heard,mdi\ns bursts svt continue,amiodarone bolus given with\n resolution. Remains a paced with occasional pvc\ns. wife updated via\n phone,see fflow sheet.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:08 ------\n" }, { "category": "Respiratory ", "chartdate": "2182-12-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 542101, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 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: Oral\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: Rhonchi\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: Continuous invasive ventilation\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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Wean fast when appropriate\n" }, { "category": "Echo", "chartdate": "2182-12-06 00:00:00.000", "description": "Report", "row_id": 86777, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 165\nBSA (m2): 1.87 m2\nBP (mm Hg): 132/72\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 08:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.\nModerate-severe regional left ventricular systolic dysfunction. TDI E/e' >15,\nsuggesting PCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; basal anteroseptal - hypo; mid anteroseptal - akinetic; basal\ninferoseptal - hypo; mid inferoseptal - akinetic; basal inferior - akinetic;\nmid inferior - akinetic; anterior apex - akinetic; septal apex- akinetic; apex\n- dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity size is normal. There is moderate regional left\nventricular systolic dysfunction with inferior and septal akinesis and apical\nakinesis/dyskinesis. Overall left ventricular systolic function is moderately\nto severely depressed (LVEF= 30 %). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). Right ventricular\nchamber size and free wall motion are normal. The right ventricular free wall\nis hypertrophied. The aortic valve leaflets are mildly thickened. The mitral\nvalve leaflets are mildly thickened. Mild (1+) 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. The pulmonic valve leaflets are thickened. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1043758, "text": ", R. CSURG CSRU 4:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal-will be i\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal-will be in CVICU approx 3:30\n PM- please call first\n ______________________________________________________________________________\n PFI REPORT\n There is a left apical pneumothorax and left pneumomediastinum and left-sided\n subcutaneous air. The endotracheal tube tip is 6.4 cm from the carina and\n could be further advanced. There is a left-sided chest tube.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1043757, "text": " 4:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal-will be i\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal-will be in CVICU approx 3:30\n PM- please call first\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 7:23 PM\n There is a left apical pneumothorax and left pneumomediastinum and left-sided\n subcutaneous air. The endotracheal tube tip is 6.4 cm from the carina and\n could be further advanced. There is a left-sided chest tube.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP SUPINE CHEST RADIOGRAPH\n\n HISTORY: 76-year-old man status post CABG x4.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There is an endotracheal tube whose tip terminates 6.4 cm from the\n carina. There is a Swan-Ganz catheter entering through the right internal\n jugular and the tip terminating in the approximate area of the right pulmonary\n artery. There are bilateral chest tubes. There is a nasogastric tube whose\n tip terminates in the stomach and side port in the stomach. There is a small\n left apical pneumothorax and left pneumomediastinum. There is left-sided\n subcutaneous air in the neck.\n\n There is bilateral basilar atelectasis and left mid lung linear atelectasis.\n There are no pleural effusions. There are degenerative changes of the\n thoracolumbar spine. The remainder of the osseous and soft tissue structures\n are unremarkable.\n\n IMPRESSION:\n 1. Left apical pneumothorax, left pneumomediastinum, and left subcutaneous\n air.\n 2. Multiple support lines including endotracheal tube 6.3 cm from the carina\n and tip could be advanced slightly for standard positioning.\n 3. Bibasilar atelectasis.\n\n The findings of the study were communicated with from the\n cardiac surgical service at 5:10 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2182-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044018, "text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PTX S/P LEFT CT REMOVAL\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx left chest tube on water seal\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:55 AM\n Small left apical pneumothorax, attention to this area on the subsequent\n studies would be recommended. Slight interval worsening of volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after CABG.\n\n Portable AP chest radiograph was compared to .\n\n The heart size is unchanged, mildly enlarged. Mediastinal sutures are\n unremarkable. There is interval minimal increase in bronchial wall thickening\n and perihilar opacities suggesting worsening of the fluid overload. Bibasal\n linear opacities are consistent with atelectasis. Note is made of the\n distention of the stomach and large bowel.\n\n Left apical pneumothorax is demonstrated, small. On the prior study, the\n presence of the pneumothorax was equivocal.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1044019, "text": ", R. CSURG FA6A 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PTX S/P LEFT CT REMOVAL\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx left chest tube on water seal\n ______________________________________________________________________________\n PFI REPORT\n Small left apical pneumothorax, attention to this area on the subsequent\n studies would be recommended. Slight interval worsening of volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1043944, "text": " 4:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx s/p mt removal, pleural on water seal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx s/p mt removal, pleural on water seal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube on waterseal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of , all of the tubes have been\n removed except for the right IJ sheath. Left chest tube remains in place on\n waterseal. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1044471, "text": " 9:41 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pneumothorax and pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax and pleural effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 11:45 AM\n Equivocal left pneumothorax. Minimal subcutaneous emphysema improved. Small\n bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PA AND LATERAL\n\n REASON FOR EXAM: Status post CABG, evaluate for pneumothorax and pleural\n effusion.\n\n Since , cardiomegaly is unchanged. Small bilateral pleural\n effusions improved. Tiny left pneumothorax is equivocal. Minimal\n subcutaneous emphysema decreased. There is no volume overload and no other\n change.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "RENAL U.S.", "row_id": 1043054, "text": " 2:52 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: HYPERTENSIVE - ? RAS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n renal doppler to evaluate flow ? of renal artery stenosis on left\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:59 PM\n No evidence of renal artery stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with coronary artery disease. Evaluate for renal\n artery stenosis.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The right kidney measures 10.9 cm and the left kidney measures 10.1\n cm. There is no hydronephrosis and no stones or solid masses are identified\n in either kidney.\n\n DOPPLER EXAMINATION: Color Doppler and pulse wave Doppler images were\n obtained. The arterial waveforms of the main renal artery in both the right\n and left kidneys are symmetrical. Normal resistive indices are seen in the\n arterial waveforms of the intraparenchymal arteries bilaterally.\n\n IMPRESSION: No evidence of renal artery stenosis. No hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "RENAL U.S.", "row_id": 1043055, "text": ", R. CSURG FA6A 2:52 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: HYPERTENSIVE - ? RAS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n renal doppler to evaluate flow ? of renal artery stenosis on left\n ______________________________________________________________________________\n PFI REPORT\n No evidence of renal artery stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1043056, "text": " 2:53 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: BRUIT, PREOP\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n r/o stenosis ? bruit\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Bruit.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque identified. On the right, peak systolic velocities are _____, 70 and\n 95 in the ICA, CCA and ECA respectively. The ICA/CCA ratio is 0.8. This is\n consistent with less than 40% stenosis.\n\n On the left, peak systolic velocities are 62, 69 and 88 in the ICA, CCA and\n ECA respectively. The ICA/CCA ratio is 0.9. This is consistent with less\n than 40% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1043057, "text": " 2:53 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: SOB\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS DUPLEX, LOWER EXTREMITY\n\n REASON: Shortness of breath.\n\n FINDINGS: Duplex evaluation was performed of both lower extremity venous\n systems. From the tibial veins to the common femoral vein, there is no\n evidence of thrombus or obstruction. There is normal compression,\n augmentation and phasicity.\n\n IMPRESSION: No evidence of DVT in either lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1043058, "text": " 2:53 PM\n DUP EXTEXT BIL (MAP/DVT); -76 BY SAME PHYSICIAN # \n Reason: vein mapping preop for cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n vein mapping preop for cabg\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS DUPLEX, LOWER EXTREMITY\n\n REASON: CABG, preop.\n\n FINDINGS: Duplex evaluation was performed of both lower extremities. The\n greater saphenous vein on the right is patent with diameters of 0.19 and 0.3,\n the lesser 0.14-0.22. On the left, the greater shows diameters of 0.18-0.3 in\n the lesser 0.17-0.26.\n\n IMPRESSION: Patent bilateral greater and lesser saphenous veins with\n diameters as noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1043796, "text": " 9:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate lt apical ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate lt apical ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG, to evaluate for apical pneumothorax.\n\n In comparison with the study of , the degree of pneumomediastinum on the\n left appears to be somewhat less. The apical pneumothorax is essentially\n unchanged. Subcutaneous gas in the left supraclavicular region is unchanged.\n\n Appearance of the heart and lungs is essentially unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1044472, "text": ", R. CSURG FA6A 9:41 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pneumothorax and pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax and pleural effusions\n ______________________________________________________________________________\n PFI REPORT\n Equivocal left pneumothorax. Minimal subcutaneous emphysema improved. Small\n bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1043086, "text": " 4:24 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate lungs, smoking hx and dyspnea - no contrast - any q\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n evaluate lungs, smoking hx and dyspnea - no contrast - any questions please\n page thank you\n CONTRAINDICATIONS for IV CONTRAST:\n RAS\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST DATED \n\n No prior CT scans for comparison.\n\n INDICATION: Smoking history. Dyspnea.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed without intravenous or oral contrast. Images are presented for\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\n multiplanar reformation images were also submitted for review.\n\n FINDINGS: Moderate degree of emphysema is present, with centrilobular and\n upper lobe predominance. A lesser component of paraseptal features are\n present predominantly at the apices. Widespread bronchial wall thickening is\n present bilaterally, and lower lobe peribronchiolar ground-glass opacities are\n present, worse on the right than the left. At the lung bases, there is\n widespread smooth septal thickening.\n\n Additionally, four noncalcified lung nodules are identified, with the largest\n in the right middle lobe lateral segment located centrally measuring 6 x 4 mm\n (image 144, series 4). Additional nodules include 3-mm peripheral right\n middle lobe nodule (152, 4), 5-mm peripheral left lower lobe nodule (169,4)\n and 4-mm peripheral left lower lobe nodule (image 195, series 4).\n\n Subcentimeter mediastinal lymph nodes are present, none individually meeting\n size criteria for abnormal enlargement. Borderline right hilar nodes are also\n noted. Heart size is normal. Three-vessel coronary artery calcification is\n noted as well as aortic valvular calcification. The heart size is normal. No\n pericardial or pleural effusion is observed.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\n made of extensive calcification in the abdominal aorta and proximal renal\n arteries. Both kidneys appear slightly heterogeneous with small foci of\n calcification, more pronounced on the right than the left. There is also a\n small cystic lesion in the upper pole portion of the left kidney. Contrast is\n present within the gallbladder as well as probable dependent stones, and renal\n parenchyma appears slightly hyperdense compared to the liver and spleen. Tiny\n punctate calcified granuloma is incidentally noted in the liver.\n\n (Over)\n\n 4:24 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate lungs, smoking hx and dyspnea - no contrast - any q\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Graft material is present in the anterior abdominal wall, possibly for prior\n hernia repair.\n\n Degenerative changes are present within the spine. No suspicious lytic or\n blastic skeletal lesions.\n\n IMPRESSION:\n 1. Moderate emphysema.\n\n 2. Bibasilar septal thickening and peribronchiolar ground-glass opacities,\n probably representing CHF with hydrostatic pulmonary edema, but differential\n diagnosis includes a viral pneumonia as well as more chronic interstitial\n diseases.\n\n 3. Four noncalcified pulmonary nodules measuring up to 6 mm in diameter.\n Followup CT in six months is recommended per the guidelines to\n exclude the possibility of a small lung cancer. At that time, the\n interstitial abnormalities can be reassessed for resolution.\n\n 4. High attenuation of the gallbladder suggesting vicarious excretion of\n contrast. As the patient received recent iodinated contrast administration,\n there are also apparent dependent small calcified gallstones.\n\n 5. Marked atherosclerotic calcifications in the abdominal aorta and proximal\n renal arteries.\n\n 6. Punctate calcifications in the kidneys and small cystic lesion in upper\n pole of the left kidney.\n\n 7. Three-vessel marked coronary artery calcifications.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1043090, "text": " 4:39 PM\n CHEST (PA & LAT) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD.\n\n FINDINGS: No previous images. Hyperexpansion of the lungs and enlargement of\n the cardiac silhouette. Prominence of interstitial markings could reflect\n chronic lung disease, increased pulmonary venous pressure, or both.\n\n No acute focal pneumonia or pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2182-12-12 00:00:00.000", "description": "Report", "row_id": 224181, "text": "Artifact is present. Probable sinus rhythm with frequent ventricular ectopy.\nLeft axis deviation. There are Q waves in the inferior leads consistent with\nprobable prior inferior myocardial infarction. The are Q waves in the anterior\nleads consistent with prior anterior myocardial infarction. Compared to the\nprevious tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2182-12-10 00:00:00.000", "description": "Report", "row_id": 224182, "text": "Sinus rhythm. Left axis deviation. Inferior myocardial infarction of\nindeterminate age. Consider anteroseptal myocardial infarction of\nindeterminate age. T wave abnormalities. Since the previous tracing\nof T wave abnormalities are more prominent.\n\n" }, { "category": "ECG", "chartdate": "2182-12-05 00:00:00.000", "description": "Report", "row_id": 224183, "text": "Sinus bradycardia. Left axis deviation. There are Q waves in the inferior\nleads consistent with prior myocardial infarction. There is a late transition\nwith anterior Q waves consistent with probable prior anterior myocardial\ninfarction. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2183-11-26 00:00:00.000", "description": "Report", "row_id": 307775, "text": "Sinus rhythm with ventricular premature beats. Otherwise, probably normal\ntracing although baseline artifact in lead V6 makes assessment difficult. No\nprevious tracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2183-11-26 00:00:00.000", "description": "Report", "row_id": 307776, "text": "Sinus rhythm. Compared to the previous tracing of ventricular ectopy\nhas resolved.\n\n" }, { "category": "ECG", "chartdate": "2183-12-02 00:00:00.000", "description": "Report", "row_id": 307772, "text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2183-12-01 00:00:00.000", "description": "Report", "row_id": 307773, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing ST-T wave\nchanges have resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2183-11-29 00:00:00.000", "description": "Report", "row_id": 307774, "text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nST-T wave changes are new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 1110298, "text": ", R. MED TSICU 12:15 PM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man found unconscious, ? attacked with a bat\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. No evidence of acute vertebral compression fracture or other injury\n involving the thoracolumbar spine.\n\n 2. Prominent Schmorl nodes in the L1 and L2 superior endplates, with\n associated chronic-appearing compression and anterior wedge deformity, but no\n spinal canal compromise.\n\n 3. L4-5: Multifactorial severe spinal canal and left more than right neural\n foraminal stenosis with significant compression of the thecal sac and likely\n impingement upon the exiting left L4 nerve root.\n\n 4. Likely incomplete manifestation of DISH involving the thoracolumbar spine\n with evident fusion at the L5-S1 level, incompletely imaged.\n\n 5. Limited imaging of the lungs with paraseptal emphysema at the left apex\n and evident bibasilar dependent atelectasis, as well as chronic\n bronchiectasis, with apparent interlobular septal thickening, of unclear\n significance.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1110226, "text": " 2:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ich/fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ? head trauma, intoxicated\n REASON FOR THIS EXAMINATION:\n ? ich/fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc WED 3:02 AM\n no acute intracranial abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intoxicated patient with question of head trauma.\n\n COMPARISON: Concurrent CT of the cervical spine.\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: There is no intracranial hemorrhage, edema, mass effect or vascular\n territorial infarction. The ventricles and sulci are normal in size and in\n configuration. There is hypodensity in periventricular white matter\n hypodensity, bilaterally, reflecting a sequela of chronic microvascular\n infarction, with chronic lacunes in the left corona radiata and putamen.\n\n While there is no acute facial or skull fracture, there is evidence of old\n fracture-deformity of the nasal bones (3:). There is circumferential\n mucosal thickening involving both maxillary sinuses, which appear\n \"atelectatic\" and, more minimally, in the anterior ethmoidal air cells and\n fronto-ethmoidal recesses, bilaterally. Abundant secretions layer dependently\n in the nasopharynx, with small fluid levels in both sphenoid air cells, likely\n related to the presence of an endotracheal tube.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Chronic microvascular and lacunar infarction.\n 3. Chronic sinus inflammatory disease.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1110227, "text": " 2:03 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? c-spine fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ? head trauma, intoxicated\n REASON FOR THIS EXAMINATION:\n ? c-spine fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc WED 3:07 AM\n no fracture or traumatica malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intoxicated patient with possible head trauma.\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 COMPARISON: Concurrent CT of the head.\n\n FINDINGS: There is no fracture or traumatic malalignment. There is no\n prevertebral soft tissue hemorrhage or edema, though assessment may be\n limited by the presence of the ET tube, with abundant surrounding secretions.\n There is confluent, exuberant ossification of the anterior longitudinal\n ligament is from C5/6 through C7/T1 levels, partially interrupted at both its\n rostral and caudal margins (400b:21-27), likely chronic. There is no\n ossification of the posterior longitudinal ligament or the ligamenta flava.\n The intracranial contents are better characterized on the concurrent dedicated\n study. Atherosclerotic mural alcification is seen in the both carotid\n bifurcations, more prominent on the right. The included portion of the lung\n apices is unremarkable.\n\n IMPRESSION:\n 1. No acute fracture or traumatic malalignment.\n 2. Exuberant ossification of the ALL, from C5/6 through C7/1, likely related\n to underlying DISH (based on limited single AP radiograph of the chest);\n though this is interrupted, there is no evidence of acute fracture.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110228, "text": " 2:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube place\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with intubation after sz\n REASON FOR THIS EXAMINATION:\n tube place\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation for seizures.\n\n A bedside frontal radiograph of the chest is taken with the patient placed on\n a trauma board. An endotracheal tube terminates approximately 4.6 cm above\n the carina. The lungs are clear. There is no pleural effusion or\n pneumothorax. The cardiac silhouette is normal. Slight prominence to the\n left aspect of the upper mediastinal contour is visualized, likely technical.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 1110297, "text": " 12:15 PM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man found unconscious, ? attacked with a bat\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT WED 4:35 PM\n PFI:\n\n 1. No evidence of acute vertebral compression fracture or other injury\n involving the thoracolumbar spine.\n\n 2. Prominent Schmorl nodes in the L1 and L2 superior endplates, with\n associated chronic-appearing compression and anterior wedge deformity, but no\n spinal canal compromise.\n\n 3. L4-5: Multifactorial severe spinal canal and left more than right neural\n foraminal stenosis with significant compression of the thecal sac and likely\n impingement upon the exiting left L4 nerve root.\n\n 4. Likely incomplete manifestation of DISH involving the thoracolumbar spine\n with evident fusion at the L5-S1 level, incompletely imaged.\n\n 5. Limited imaging of the lungs with paraseptal emphysema at the left apex\n and evident bibasilar dependent atelectasis, as well as chronic\n bronchiectasis, with apparent interlobular septal thickening, of unclear\n significance.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE THORACIC SPINE WITHOUT CONTRAST, \n\n HISTORY: 50-year-old man found unconscious, ? attacked with a bat; evaluate\n for fracture.\n\n TECHNIQUE: Helical 3.75-mm axial MDCT sections were obtained from the T1\n through L5 inferior endplate level, without IV contrast administration;\n sagittal and coronal reformations were prepared, and all images are viewed in\n bone, soft tissue and lung window on the workstation.\n\n FINDINGS: There are no comparison studies on record, and there is no\n radiographic skin marker to indicate a specific site of injury. There is no\n paraspinal, prevertebral or other retroperitoneal or evident thoracolumbar\n spinal epidural hematoma. Other than a possible gentle thoracolumbar\n S-scoliosis, dextroconvex in the thoracic spine, the alignment is normal.\n There is no evidence of acute compression fracture. There are prominent\n Schmorl nodes in the L1 and L2 superior endplates, with associated\n chronic-appearing compression and anterior wedge deformity. However, there is\n no retropulsion of the dorsal vertebral cortex or spinal canal compromise.\n (Over)\n\n 12:15 PM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is flowing, though interrupted, ossification of the right-sided anterior\n longitudinal ligament complex at the C7-T1, T2-3, T4-5 and T9-10 levels,\n suggesting (but not meeting strict definitional criteria for) DISH; there is\n evident osseous fusion at the L5-S1 level. Also noted are prominent\n disc-spondylotic ridges involving the L1 inferior and L2 superior endplates\n with some ventral narrowing of the spinal canal at this disc space level.\n Congenitally abnormal canal geometry, as well as disc bulging and marked\n thickening and ossification of the ligamenta flava, result in severe narrowing\n of the spinal canal at the L4-5 level with maximal transverse dimension of\n only 6 mm, and significant deformity of the thecal sac. There is also\n significant narrowing of both neural foramina due to L4 inferior endplate and\n facet spondylosis. These findings are worse on the left, where there is\n likely impingement upon the exiting left L4 nerve root. The thoracolumbar\n spinal canal otherwise appears patent, throughout.\n\n There are endotracheal and endogastric tubes in situ. The limited included\n medial portion of the lungs is notable for left apical paraseptal emphysema,\n dependent atelectasis, dorsally, and, particularly at the lung bases,\n bronchiectasis and likely scattered scarring, and thickening of the\n interlobular septae, of uncertain significance.\n\n IMPRESSION:\n\n 1. No evidence of acute vertebral compression fracture or other injury\n involving the thoracolumbar spine.\n\n 2. Prominent Schmorl nodes in the L1 and L2 superior endplates, with\n associated chronic-appearing compression and anterior wedge deformity, but no\n spinal canal compromise.\n\n 3. L4-5: Multifactorial severe spinal canal and left more than right neural\n foraminal stenosis, with significant compression of the thecal sac and likely\n impingement upon the exiting left L4 nerve root.\n\n 4. Likely forme fruste DISH involving the thoracolumbar spine, with evident\n fusion at the L5-S1 level, incompletely imaged.\n\n 5. Paraseptal emphysema at the left lung apex and evident bibasilar dependent\n atelectasis, chronic bronchiectasis and scarring, which may relate to prior\n aspiration episodes, and apparent interlobular septal thickening, of unclear\n significance; these findings are incompletely imaged.\n\n COMMENT: These findings were discussed with Dr. (the houseofficer\n caring for the patient), by Dr. , at time of dictation on .\n (Over)\n\n 12:15 PM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2183-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110362, "text": " 4:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm OG tube placement, patient pulled it part-way\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ?found down.\n REASON FOR THIS EXAMINATION:\n Please confirm OG tube placement, patient pulled it part-way out.\n ______________________________________________________________________________\n WET READ: JXRl WED 9:14 PM\n Enteric tube is high, terminating at GE junction. ETT 5cm above carina. d/w\n 915pm .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male found down, status post nasogastric tube\n placements.\n\n COMPARISON: Chest radiographs available from at 2:26 a.m.\n\n SUPINE AP VIEW OF THE CHEST:\n The heart size is normal. The hilar and mediastinal contours are within\n normal limits. The patient is status post intubation with endotracheal tube\n terminating 5.1 cm above the carina. A nasogastric tube terminates at the GE\n junction. The lungs are well expanded and clear bilaterally with no evidence\n of pneumothorax or pleural effusion.\n\n IMPRESSION: Nasogastric tube terminating at the GE junction. Endotracheal\n tube 5.1 cm above the carina. These findings were discussed by Dr. \n with Dr. at 9:15 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2183-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110946, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with polysubstance abuse, found down, withdrawl, concern for\n aspiration.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Substance abuse, found down, to evaluate for aspiration.\n\n FINDINGS: In comparison with the study of , there is a decrease in the\n right basilar consolidation, consistent with resolving aspiration pneumonia.\n The left base now is essentially clear.\n\n No vascular congestion or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-27 00:00:00.000", "description": "ORBITS PRE-MRI (WATERS LOOK UP&DOWN)", "row_id": 1110552, "text": " 2:58 PM\n ORBITS PRE-MRI (WATERS LOOK UP&DOWN) Clip # \n Reason: Possible density\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with density. Need extra views to r/o for metal so can have\n MRI. Please get , lateral, and waters.\n REASON FOR THIS EXAMINATION:\n Possible density\n ______________________________________________________________________________\n FINAL REPORT\n ORBIT FILM TWO VIEWS DATED \n\n CLINICAL HISTORY: Pre-MRI screening, question of radiodensity on prior orbit\n film.\n\n COMPARISONS: Orbit film done earlier the same day.\n\n FINDINGS: The previously identified radiodensity in the left lateral orbit is\n no longer visualized, and likely was artifactual in nature. There is no\n evidence of a radiodensity within the orbits on today's study. Endotracheal\n tube is again noted. There is mild mucosal sinus disease.\n\n IMPRESSION: No evidence of an orbital radiopaque density.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110553, "text": " 2:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with fevers and sepsis\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with fevers and sepsis.\n\n COMPARISON: Chest radiograph available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST:\n There is an endotracheal tube terminating 5 cm above the level of the carina.\n A nasogastric tube terminates appropriately within the stomach. The heart\n size is normal. Hilar and mediastinal contours are within normal limits and\n unchanged from prior exam. There is a new subtle opacity within the right\n lower lobe that may represent an early infiltrative process. There is no\n pneumothorax or pleural effusion. The left costophrenic angle is excluded\n from the study.\n\n IMPRESSION: New subtle opacity within the right lower lobe may represent an\n early infiltrative process.\n\n Findings communicated by Dr. to Dr. at 4:30PM on .\n\n" }, { "category": "Radiology", "chartdate": "2183-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110592, "text": " 8:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube location corrected\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with recent OGT adjustment\n REASON FOR THIS EXAMINATION:\n OG tube location corrected\n ______________________________________________________________________________\n WET READ: 9:14 PM\n Enteric tube has been advanced, remains in stomach, directed cephalad.\n Progressive right basilar opacity in comparison to 5 hour prior. d/w Dr\n 9:10pm .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 50-year-old male with recent orogastric tube adjustments.\n\n COMPARISON: Chest radiograph available from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: An endotracheal tube terminates 5.3 cm\n above the level of the carina. The orogastric tube remains in the stomach,\n there is a persistent right basilar opacity seen on the prior chest radiograph\n on at 3:38 p.m., which has increased in density and is now\n associated with elevated right hemidiaphragm. These findings are compatible\n with focal volume loss in the context of an infiltrative process.\n\n IMPRESSION:\n 1. Orogastric tube remains within the stomach.\n 2. The endotracheal tube terminates 5.3 cm above the level of the carina.\n 3. Persistent right basilar opacity, now with new elevated right\n hemidiaphragm, compatible with local volume loss and concerning for pneumonia.\n\n Initial findings were discussed by Dr. to Dr. at 9:10\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2183-11-28 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1110617, "text": " 12:43 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: ?cervical trauma\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man in ICU with sepsis, also with cervical tenderness. r/o\n cervical trauma.\n REASON FOR THIS EXAMINATION:\n ?cervical trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE MRI DATED \n\n CLINICAL HISTORY: A 58-year-old male in ICU with sepsis, also with cervical\n tenderness, rule of cervical trauma.\n\n TECHNIQUE: MRI of the cervical spine was performed without the use of\n intravenous contrast, as per the standard departmental protocol. Imaging\n sequences included sagittal FRFSE T2, sagittal T1, sagittal STIR, and axial\n GRE.\n\n COMPARISONS: Cervical spine CT dated .\n\n FINDINGS: The vertebral body height and alignment is maintained. There is a\n normal cervical lordosis. There is increased T2 signal intensity in the\n anterior aspect of the C5 and C6 vertebral bodies adjacent to the calcified\n anterior longitudinal ligament, likely on a degenerative basis. There is no\n evidence of abnormal T2 signal in the adjacent soft tissues or in the anterior\n longitudinal ligament itself to suggest an acute injury.\n\n The visualized cord demonstrates normal signal intensity. The posterior fossa\n is unremarkable.\n\n There are some secretions in the hypo- and oropharynx, likely related to the\n intubation.\n\n C2-3: Unremarkable.\n\n C3-4: Mild diffuse disc bulge and endplate osteophytes result in flattening\n along the ventral aspect of the thecal sac, but without spinal cord\n encroachment. Mild uncovertebral osteophytes result in mild left greater than\n right neural foraminal narrowing.\n\n C4-5: There is a central disc protrusion, without significant spinal cord\n encroachment. Mild uncovertebral osteophytes are also present, resulting in\n mild left neural foraminal narrowing.\n\n C5-6: A diffuse disc bulge results in flattening of the ventral aspect of the\n thecal sac, without significant spinal cord encroachment. Mild-to-moderate\n left neural foraminal narrowing is noted secondary to uncovertebral\n osteophytes and facet hypertrophy.\n (Over)\n\n 12:43 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: ?cervical trauma\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n C6-7: There are endplate osteophytes and a diffuse disc bulge resulting in\n ridging along the ventral aspect of the thecal sac and flattening along the\n ventral aspect of the spinal cord which appears to be remodeled. The spinal\n canal remains capacious. Mild left greater than right neural foraminal\n narrowing is present secondary to uncovertebral osteophytes and facet\n hypertrophy.\n\n C7-T1: There are minimal degenerative changes, without significant spinal\n canal or neural foraminal encroachment.\n\n IMPRESSION: Ossification of the anterior longitudinal ligaments with\n associated degenerative chagnes, but without evidence of ligamentous injury or\n an acute fracture or dislocation. There is no evidence of spinal cord\n compromise.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110636, "text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA status\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ? RLL PNA\n REASON FOR THIS EXAMINATION:\n PNA status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 50-year-old male with right lower lobe pneumonia.\n\n COMPARISON: Chest radiographs available from at 11:00 p.m.\n\n SEMI-ERECT AP VIEW OF THE CHEST:\n The heart size is normal. Hilar and mediastinal contours are unchanged.\n There is persistent pulmonary vascular congestion. The overall lung expansion\n is improved, particularly on the right, in comparison to the prior chest\n radiograph. There is a right basilar hazy opacity that partially obscures the\n right hemidiaphragm, with an interval increase in density. There is no\n pneumothorax or pleural effusion.\n\n An endotracheal tube terminates 4.2 cm below the carina. An orogastric tube\n extends to at least the level of the stomach; however, the termination point\n is excluded from the study.\n\n IMPRESSION:\n 1. Persistent right lower lobe opacity is compatible with evolving pneumonia.\n 2. Improved lung expansion since the prior study.\n 3. Endotracheal tracheal tube 4.2 cm above the level of the carina.\n 4. Orogastric tube terminates beyond the scope of this study.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-27 00:00:00.000", "description": "P SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING PORT", "row_id": 1110477, "text": " 10:43 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING PORT Clip # \n Reason: scout films to ensure no metal prior to MRI\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with sepsis, likely aspiration PNA, also with c-spine\n tenderness, plan to obtain MRI to r/o c-spine injury.\n REASON FOR THIS EXAMINATION:\n scout films to ensure no metal prior to MRI\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 50-year-old male with sepsis, likely aspiration pneumonia,\n with C-spine tenderness; pre-screen MRI prior to cervical spine MRI to\n evaluate for injury.\n\n TECHNIQUE: A Waters view of the skull, an AP view of the abdomen and chest as\n well as a lateral view of the cervical spine were obtained.\n\n COMPARISONS: Head CT dated .\n\n FINDINGS:\n\n ORBITS: There is a tiny radiodense focus in the superior outer aspect of the\n left orbit, which may be artifactual in nature or could represent a true\n radiodensity. This may be within the orbit or could be in more posterior soft\n tissues. An endotracheal tube is in position. There may be mild paranasal\n sinus disease.\n\n CERVICAL SPINE: A single lateral view of the cervical spine demonstrates no\n evidence of radiopaque foreign body. There is an endotracheal tube in\n position. Other catheters overlie the patient. The vertebral body height and\n alignment is maintained.\n\n CHEST: The endotracheal tube is in position, with the tip approximately 4.4\n cm above the carina. There is no evidence of a pacemaker. Catheters and EKG\n leads overlie the patient, presumably outside the patient, which can be\n confirmed by direct visualization.\n\n The visualized lungs are clear. There is no evidence of pneumonia or\n pulmonary edema. The cardiac and mediastinal silhouette are unremarkable.\n There is fullness of the hila, with enlargement of the soft tissues of the\n right paratracheal stripe.\n\n ABDOMEN: EKG leads again overlie the patient, presumably external to the\n patient. There is no evidence of another radiopaque foreign body. Soft\n tissue planes are unremarkable. The visualized bowel gas pattern is normal.\n Degenerative changes are noted throughout the spine, most marked at L2, where\n there is loss of vertebral body height, age indeterminate.\n\n IMPRESSION:\n 1. Tiny radiodensity overlying the left orbit, which may be artifactual in\n nature, although it is possible that it is within the orbit. A repeat Waters\n (Over)\n\n 10:43 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING PORT Clip # \n Reason: scout films to ensure no metal prior to MRI\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n view as well as lateral and view may be helpful for further\n evaluation.\n 2. Prominence of the hila and fullness along the right paratracheal stripe,\n raising the possibility of adenopathy.\n 3. Compression deformity of L2 at the superior endplate, age indeterminate.\n 4. Aside from EKG leads and catheters that presumably overlie the patient\n (for which direct inspection can determinate this), no radiopaque foreign body\n is identified in the neck, chest, or abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110813, "text": " 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change of pneumonia (believed to be\n Admitting Diagnosis: UNRESPONSIVE AND SEIZED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with alcohol, withdrawl, polysubstance abuse.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change of pneumonia (believed to be aspiration).\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Alcohol withdrawal and polysubstance abuse.\n\n Portable AP chest radiograph was compared to .\n\n There is significant improvement of the right basal consolidation consistent\n with resolution of aspiration or combination of aspiration and atelectasis.\n There is still present mild vascular engorgement. No overt pneumothorax or\n pleural effusion has been demonstrated.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-01-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1169843, "text": " 2:06 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o acute cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with cp while shovelling snow this morning.\n REASON FOR THIS EXAMINATION:\n r/o acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old woman with chest pain while shoveling snow this\n morning. Please rule out acute cardiopulmonary process.\n\n TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS:\n There is subtle increased density in the right lower lobe likely atelectasis.\n Mild left basilar atelectasis is also noted. There is no pleural effusion or\n pneumothorax. Cardiomediastinal silhouette and hila are normal. No displaced\n fracture is seen.\n\n IMPRESSION:\n Mild bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2180-01-13 00:00:00.000", "description": "CARDIAC PERFUSION", "row_id": 1170138, "text": "CARDIAC PERFUSION Clip # \n Reason: LAD LESION, NEW APICAL AM, ? ISCHEMIA VIABILITY\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 10.4 mCi Tc-m Sestamibi Rest ();\n 32.7 mCi Tc-99m Sestamibi Stress ();\n HISTORY: 72 y.o. s/p NSTEMI on , with 60-70% proximal LAD lesion,\n referred for evaluation of viability and ischemia.\n\n SUMMARY OF DATA FROM THE EXERCISE LAB:\n\n Exercise protocol: \n Resting heart rate: 70\n Resting blood pressure: 94/56\n Exercise Duration: 3.75 minutes\n Peak heart rate: 93\n Percent maximum predicted heart rate obtained: 63%\n Peak blood pressure: 82/52\n Symptoms during exercise: None\n Reason exercise terminated: Drop in systolic blood pressure\n ECG findings: No ST changes\n\n METHOD:\n\n Resting perfusion images were obtained with Tc-m sestamibi. Tracer was\n injected approximately 45 minutes prior to obtaining the resting images.\n\n At peak exercise, approximately three times the resting dose of Tc-m sestamibi\n was administered IV. Stress images were obtained approximately 15 minutes\n following tracer injection.\n\n Imaging Protocol: Gated SPECT\n\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n INTERPRETATION:\n\n Resting and stress perfusion images reveal a mild fixed perfusion defect of the\n apex with the perfusion otherwise unremarkable.\n\n Gated images reveal normal wall motion.\n\n The calculated left ventricular ejection fraction is 70% with an EDV of 65 mL.\n\n IMPRESSION: 1. Mild fixed apical perfusion defect, with an otherwise normal\n myocardial perfusion for the level of exercise achieved. No reversible defect\n identified. 2. Normal left ventricular function.\n\n\n (Over)\n\n CARDIAC PERFUSION Clip # \n Reason: LAD LESION, NEW APICAL AM, ? ISCHEMIA VIABILITY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n , M.D.\n , M.D. Approved: MON 8:20 AM\n West \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": "Echo", "chartdate": "2180-01-11 00:00:00.000", "description": "Report", "row_id": 96969, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. MR? Post cath\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 104/61\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 09:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Good\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild-moderate\nregional LV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nakinetic; apex - dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate\n[2+] 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\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thicknesses are normal. The left ventricular\ncavity size is normal. There is mild to moderate regional left ventricular\nsystolic dysfunction with apical akinesis/dyskinesis. Contrast administered to\nimprove visualization of the apex. No left ventricular thrombus identified.\nRight ventricular chamber size and free wall motion are normal. The aortic\narch is mildly dilated. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is\nseen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared to the prior stress echo study of , resting left\nventricular systolic function is now significantly impaired.\n\n\n" }, { "category": "ECG", "chartdate": "2180-01-11 00:00:00.000", "description": "Report", "row_id": 289061, "text": "Sinus rhythm. Since the previous tracing there are inferior and apical\nlateral T wave inversions along with Q-T interval prolongation consistent with\nanterior myocardial infarction in evolution. Clinical correlation is\nsuggested.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2180-01-11 00:00:00.000", "description": "Report", "row_id": 289062, "text": "Baseline artifact. Sinus rhythm. The Q-T interval is 420 milliseconds. Low\nvoltage. Leftward axis. Probable anteroseptal myocardial infarction, age\nundetermined. Other ST-T wave abnormalities. Since the previous tracing\nT wave amplitudes are more prominent.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2180-01-10 00:00:00.000", "description": "Report", "row_id": 285445, "text": "Sinus rhythm. Compared to tracing #3 precordial ST segment elevation is less\nprominent. T wave amplitudes in general are diminished. Clinical correlation\nis suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2180-01-10 00:00:00.000", "description": "Report", "row_id": 285446, "text": "Sinus rhythm. Compared to tracing #2 the limb lead voltage has now decreased.\nOtherwise, unchanged from previously noted findings.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2180-01-10 00:00:00.000", "description": "Report", "row_id": 285447, "text": "Sinus rhythm. Compared to tracing #1 no significant change in previously noted\nfindings. Borderline low precordial voltage persists.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-01-10 00:00:00.000", "description": "Report", "row_id": 285448, "text": "Sinus rhythm. Borderline P-R interval prolongation. Small R waves versus\nQ waves in leads V1-V3 with mild ST segment elevation. Possible anteroseptal\nmyocardial infarction, age undetermined. Since the previous tracing of \nprecordial ST segment elevation is more prominent on the present tracing.\nClinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2145-03-26 00:00:00.000", "description": "Report", "row_id": 74148, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery bypass grafting\nBP (mm Hg): 120/60\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 14:17\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 or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly depressed\nLVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; septal apex - hypo; apex - akinetic;\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. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Normal descending aorta\ndiameter. Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] 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 under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Resting bradycardia (HR<60bpm). Results\nwere personally reviewed with the MD caring for the patient. See Conclusions\nfor post-bypass data\n\nConclusions:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage.\nNo atrial septal defect is seen by 2D or color Doppler.\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is mildly depressed (LVEF= 40 %). With regional\nwall m otion abnormalities in the anterior and inferior septal walls at the\nbase, mid and apical regions.\nRight ventricular chamber size and free wall motion are normal.\nThere are complex (>4mm) atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\nDr. was notified in person of the results before surgical incision.\n\n\nPOST-BYPASS:\nNormal RV systolic function.\nOverall LVEF 40%. There is some improvement in the previously hypokinetic\nregions.\nIntact thoracic aorta.\nMild MR /.\n\n\n" }, { "category": "ECG", "chartdate": "2145-03-26 00:00:00.000", "description": "Report", "row_id": 171058, "text": "There are ineffective pacer spikes. Diffuse ST-T wave changes. The patient is\nin normal sinus rhythm. Compared to tracing #1 there are some ST-T wave changes\nthat are non-specific. No other diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-03-25 00:00:00.000", "description": "Report", "row_id": 171059, "text": "Normal sinus rhythm. Poor R wave progression. Leftward axis. Diffuse T wave\nflattening. Compared to the previous tracing of T wave voltage is\ngenerally less. Otherwise, no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-03-22 00:00:00.000", "description": "Report", "row_id": 171060, "text": "Sinus rhythm. Left anterior fascicular block. Late R wave progression related\nto left anterior fascicular block. Since the previous tracing of the\nQRS voltage in lead aVL is less prominent. ST-T wave abnormalities are\nimproved.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2131-10-18 00:00:00.000", "description": "Report", "row_id": 1605489, "text": "/02 Shift report from 7A to 7P RN\n\nPt received this am sleepiong, easily aroused. MAe, follows commands. Denies any pain or discomfort. pupils equal and brisk.Pt receives schedules ativan per tube. Hr in the high 90's to low 100's, bp low while asleep, systolic in the high 80's, stable all day. afebrile, all extremites warm ,no edema with good pulses. Has L AC PICC line from previous institution, good blood return , flushes well, site wnl.\nPt had trach revision on , new #8 trach placed. Pt is currently NPO and cannot speak at this time. Will need to come back in weeks MD for another revision, after trachea heals. Tpiece all day, resps are free and easy with no SOB. Lungs are clear. Spo2 >97%. Peg tube wnl with respolar at 40 cc/hr(goal). Positive bs, no bm today. No N/V noted. Pt voiding adequate amounts of clear yellow urine in bedpan. is warm and dry with no breakdown noted.\nPlan: D/C back to today. Mother at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2131-10-17 00:00:00.000", "description": "Report", "row_id": 1605487, "text": "PMICU Nursing Progress Note 7a-7p\n Reveiw of Sytems\n\n Pt 3, cooperative, interactive, and pleasant. Travelled to OR today for trach change and recieved fetanyl, propofol and succ while in procedure. Pt vent settings changed to PS for procedure, tolerated well. One time episode of hypotension following delivery of propofol in OR, tx w/ good effect w/ 200 LR IVB. Returned to MICU @ 1530 and recovered w/ out event, all VS WNL. PERRLA, bsk. MAE.\nCV- Hemodynamically stable. HR 80-100's, NSR, rare PVC. BP 80-100, MAPS 50-60's. Started in potassium today, cont to do lab checks.\nResp- Plan for PT to remain on PS tonight, currently 20 PS, 5 PEEP, Tv 200's, RR 20. PT can then return to routine of t-piece during the day and vent support at night tomorrow. Rigid bronch showed ulcer has healed well, but defect in anatomy remains. As a result pt was not able to have trach switched back to shiley, since pressure would be applied to formerly damaged area. Instead the plan is now to have a new smaller trach, which was ordered today. This will take two weeks to arrive, in the meantime pt will be evaluated by speech and swallow and work to bulid muscles so that she may eat again. Sats >95%, goal >92%. 3x today for thin white secretions.\nGI- Abd soft and slightly distended, +BS, no BM. Restarted on TF @ 20 cc, titrate to goal of 40cc/hr. PEJ site .\nGU- Cont on lasix w/ great response. Voids, yellow, clr urine.\n - \n Pt planned to be discharged back to rehab tomorrow, team, casemanager and family aware. Plan for her to be evaluated by rehab here before being discharged, cont supportive medical care.\n" }, { "category": "Nursing/other", "chartdate": "2131-10-18 00:00:00.000", "description": "Report", "row_id": 1605488, "text": "NPN 7p-7a\n\nPt. to be d/c to today; rep from needs to be contact to review chart prior to pt. d/c. Nursing page 2 completed, ? d/c summary from MD staff completed; will f/u with team.\n\n:\n\nPt. conts to be hemodynamically stable and stabe on ventilator. IPS decreased from 20 to 16 and pt. has remained comfortable on vent with TV 200X20-25. Sat's maintained >98%. Sx'd X1 for scant secretions. Trach care done post-op this evening; some blood tinged mucous noted at trach site. Pt. pain-free . C/o and insomnia X 1 and ativan am dose given early with good effect. Pt. slept well from 11p-5a. Pt. expressing some discouragement with lack of trach change as pt. strongly desires to eat again soon. Prior to this admission, pt. eating at rehab, ? why NPO with same trach (aspiration risk?); PLEASE FOLLOW UP with team and Dr. @ (pager) to discuss pt. wishes and eating parameters. Will need to involve speech and swallow intently. Plan at rehab with include aggressive s/s rehab to rebuild muscles in mouth and upper airways prior to trach change. Also , advanced TF to 40cc (goal rate). Pt. incontinent of urine X 2 for large amounts. Pt. given 40 PO KCL and 40 IV KCL for low midnight K+ of 3.0, will need to recheck this am about 8am. In sum, pt. stable for transfer to rehab ASAP pending issues of d/c summary and contact with MD re: eating guidelines.\n" }, { "category": "Nursing/other", "chartdate": "2131-10-16 00:00:00.000", "description": "Report", "row_id": 1605484, "text": "PMICU Nursing Admission Note 1800-1900\nPlease refer to nursing admission note for further information. PT transferred from rehab to for trach procedure tomorrow w/ Dr. . Plan is for pt to be dicharged back to following procedure.\n\nCurrent Review of Systems\n PT 3, pleasant and copperative. Cont to have ativan orders if needed. No c/o pain.\nCV- HR 80-90's, NSR, no ectopy noted. BP 80-90'a/40's, MAPS 60's. Cont to have sliding scale Potassium orders and receive lasix . Please follow up w/ team on evening potassium lab check.\nRESP- Arrived on t-piece, plan for PT to rest o/n on vent on 12 PS, 5 PEEP, 35% @. Goal sats 92%. LS absent on L from lobectomy in 94' and clr in upper lobe on R and coarse in R base. Pt alerts you to suction needs, reported to have white thin secretions. Sats 97%.\n PT NPO after midnight for OR procedure tomorrow. Until then TF may be infused @ 40cc/hr of Respalor (pulmacore used at rehab). Abs soft, slightly distended, non tender. PEJ site inact.\nGU- Voids in bedpan or comode, follow output.\n- .\nPlan- Provide supportive medical care for pt while in MICU for procedure then assist in transfer back to rehab. PT's family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2131-10-17 00:00:00.000", "description": "Report", "row_id": 1605485, "text": "Respiratory Care Note:\n\nPt received on T-piece 40% FIO2. Placed on Ventilator ~ 2100hr, MD team asked fo CPAP 12/5 ~ 35-40% FIO2. Settled on IPS 20 instead Spontaneous Vt ~ 200 ml & 40% FIO2. Comfortable O/N.\n" }, { "category": "Nursing/other", "chartdate": "2131-10-17 00:00:00.000", "description": "Report", "row_id": 1605486, "text": "NPN 1900-0700\nSeec careview for details.\n\nNEURO : AXOX3, mouths words,MAE, but generalized weakness noted. Slept well over noc after requesting trazadone.\n\nRESP: PSV 20/5 down now @ 16/5 W 40% Fio2. RR high 20's -low 30's. for min secretions.Lungs clear @ apexes w/scattered rhonchi.\n\nC/V:SR no VEA. BP labile,low of 73 systolicly, settled out in mid 80's. This is baseline for this PT.\n\nF/E/N: NPO for OR today, D51/2NS @ 75 /hr. PEG tube clamped.voided in bedpan.\n\nPlan: Repeat K+ @ 0800, OR today for trach change.\n" }, { "category": "ECG", "chartdate": "2131-10-16 00:00:00.000", "description": "Report", "row_id": 310851, "text": "Sinus rhythm\nMarked right axis deviation\nRight ventricular hypertrophy\nSince previous tracing of : junctional rhythm absent\n\n" } ]

[ { "category": "Radiology", "chartdate": "2117-02-18 00:00:00.000", "description": "RENAL U.S.", "row_id": 1005472, "text": " 10:06 AM\n RENAL U.S. Clip # \n Reason: please evaluate for renal obstruction and please evaluate bl\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ARF and bladder scan with ?hyperechoic mass\n REASON FOR THIS EXAMINATION:\n please evaluate for renal obstruction and please evaluate bladder for mass\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with ARF and bladder scan with hyperechoic mass.\n Evaluate for renal obstruction and please evaluate bladder for mass.\n\n Both kidneys are normal. There is no evidence of hydronephrosis. The right\n kidney measures 11.8 cm. The left kidney measures 11.8 cm. No focal renal\n lesions are identified. The bladder is partially distended and demonstrates\n internal echoes suggestive of clots. There is no son evidence of\n bladder mass.\n\n IMPRESSION: No hydronephrosis. No evidence of bladder mass, partially\n distended bladder with internal clots.\n\n" }, { "category": "Radiology", "chartdate": "2117-02-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1005561, "text": " 10:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm placmement and no PTX\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with new right IJ\n REASON FOR THIS EXAMINATION:\n confirm placmement and no PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE FOR LINE PLACEMENT ON AT 22:07\n\n COMPARISON: at 19:28.\n\n HISTORY: 54-year-old man with new right IJ placement and rule out\n pneumothorax.\n\n FINDINGS: A newly placed right internal jugular catheter tip is in the\n proximal-to-mid SVC in a satisfactory location. The atelectasis is slightly\n more prominent in the right mid lung. The inferior-most portion of the left\n hemithorax cannot be evaluated as it has not been included in this image. The\n visualized portions of the lungs are clear. No right pleural effusion. No\n pneumothorax.\n\n IMPRESSION:\n 1. Status post placement of a right IJ line in a satisfactory location,\n terminating approximately in the upper-to-mid SVC.\n 2. More prominent right mid lung atelectasis.\n 3. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2117-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005551, "text": " 7:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for development of infiltrates\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with C2-C4 abscess c/b quadriplegia transferred to the \n with bacteremia.\n REASON FOR THIS EXAMINATION:\n please evaluate for development of infiltrates\n ______________________________________________________________________________\n WET READ: 7:59 PM\n Slightly improved right lung linear atelectasis. -\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever in a patient with known C2-C4 abscess.\n\n PORTABLE AP CHEST RADIOGRAPH COMPARED TO , OBTAINED AT 1:41 P.M.\n\n The heart size is top normal, unchanged. The mediastinal contours are stable.\n There is no change in the appearance of the right middle lobe and superior\n segment of right lower lobe atelectasis. Linear left basilar atelectasis is\n again noted, unchanged as well. The rest of the lungs are unremarkable with\n no new areas of consolidations, worrisome for pneumonia. There is no pleural\n effusion or pneumothorax.\n\n IMPRESSION: Unchanged areas of atelectasis. Otherwise, unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2117-02-22 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1006023, "text": " 10:05 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs PICC line for a/b treatment\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with history of quadriplegia admitted with Gram +\n bacteremia/sepsis\n REASON FOR THIS EXAMINATION:\n needs PICC line for a/b treatment\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 RADIOLOGIST: Drs. and performed the procedure. Dr. ,\n the Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left basilic vein\n was punctured under direct ultrasound guidance using a micropuncture set. Hard\n 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 single lumen PICC line measuring 50 cm in length was\n then placed through the peel-away sheath with its tip positioned in the SVC\n under 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 secured\n 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 single lumen\n PICC line placement via the left basilic venous approach. Final\n internal length is 50 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2117-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005410, "text": " 8:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with paraplegia p/w fever to 103\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Paraplegia with fever of 103. Evaluate for pneumonia.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n Comparison is made to , CT chest and , CT\n examination.\n\n FINDINGS: Lungs are clear. Cardiomediastinal silhouette, hilar contours, and\n pleural surfaces are within normal limits given patient rotation. There is\n stable elevation of the right hemidiaphragm. No soft tissue or osseous\n abnormalities identified. Right PICC is again noted, however, its tip is not\n well visualized on current exam.\n\n IMPRESSION:\n\n 1. No acute cardiopulmonary process.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2117-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005502, "text": " 1:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess site if picc tip\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with picc.\n REASON FOR THIS EXAMINATION:\n Assess site if picc tip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the study of , the streak of atelectasis at\n the right base is somewhat more prominent. The tip of the PICC line is\n difficult to evaluate as it runs through the mediastinum, as on the previous\n study.\n\n\n" }, { "category": "Echo", "chartdate": "2117-02-22 00:00:00.000", "description": "Report", "row_id": 86362, "text": "PATIENT/TEST INFORMATION:\nIndication: Rule out endocarditis.\nHeight: (in) 70\nWeight (lb): 205\nBSA (m2): 2.11 m2\nBP (mm Hg): 110/70\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 17:08\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 in the body of\nthe RA. No mass or thrombus in the RA or RAA. Normal interatrial septum. No\nASD by 2D or color Doppler.\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 ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Trace 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 with\nphysiologic PR. No vegetation/mass on pulmonic valve.\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 sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthickness, cavity size, and global systolic function are normal. 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 40 cm from the incisors. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nstenosis. No masses or vegetations are seen on the aortic valve. Trace aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. No mass or vegetation is seen on the mitral\nvalve. No vegetation/mass is seen on the tricuspid or pulmonic valve. There is\nno pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis.\n\n\n" }, { "category": "Echo", "chartdate": "2117-02-19 00:00:00.000", "description": "Report", "row_id": 86363, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 71\nWeight (lb): 216\nBSA (m2): 2.18 m2\nBP (mm Hg): 90/60\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 08:58\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 and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Mildly 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: 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 AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nNormal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\npatient unable to cooperate.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%) The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No masses or vegetations are seen on the\naortic valve, but cannot be fully excluded due to suboptimal image quality. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. No masses or vegetations are seen on the\nmitral valve, but cannot be fully excluded due to suboptimal image quality.\nThe tricuspid valve leaflets are mildly thickened. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\nIMPRESSION: No vegetation or significant valvular regurgitation seen.\nDilatation and hypokinesis of the right ventricle.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "ECG", "chartdate": "2117-02-17 00:00:00.000", "description": "Report", "row_id": 214715, "text": "Sinus tachycardia. Non-specific ST segment changes and increase in rate as\ncompared with prior tracing of . Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "Nursing", "chartdate": "2117-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 408347, "text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Hematuria\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 97.7 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Unknown;\n Precautions: Contact\n PMH: Hepatitis\n CV-PMH:\n Additional history: Quadriplegia r/t C2-C4 abcess .\n Stage IV Sacral Decub\n Muscle Spasms/Chronic Pain\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\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 None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 705 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:50 AM\n Potassium:\n 3.2 mEq/L\n 04:50 AM\n Chloride:\n 104 mEq/L\n 04:50 AM\n CO2:\n 24 mEq/L\n 04:50 AM\n BUN:\n 31 mg/dL\n 04:50 AM\n Creatinine:\n 1.3 mg/dL\n 04:50 AM\n Glucose:\n 91 mg/dL\n 04:50 AM\n Hematocrit:\n 24.0 %\n 07:48 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": "2117-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 408348, "text": "54 yo man w/ PMH of quadriplegia r/t C2-C4 abscess, and stage IV\n decubitus ulcer on coccyx. Pt recently had two recent extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria. Received 3 units PRBC\ns. Hematuria improved following manual\n bladder irrigation by urology and cont CBI.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Hematuria\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 97.7 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Unknown;\n Precautions: Contact\n PMH: Hepatitis\n CV-PMH:\n Additional history: Quadriplegia r/t C2-C4 abcess .\n Stage IV Sacral Decub\n Muscle Spasms/Chronic Pain\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\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 None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 705 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:50 AM\n Potassium:\n 3.2 mEq/L\n 04:50 AM\n Chloride:\n 104 mEq/L\n 04:50 AM\n CO2:\n 24 mEq/L\n 04:50 AM\n BUN:\n 31 mg/dL\n 04:50 AM\n Creatinine:\n 1.3 mg/dL\n 04:50 AM\n Glucose:\n 91 mg/dL\n 04:50 AM\n Hematocrit:\n 24.0 %\n 07:48 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": "Physician ", "chartdate": "2117-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 408349, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 11:00 PM\n BLOOD CULTURED - At 04:50 AM\n - urology consulted for gross hematuria & hct drop, recommended CBI &\n hourly flushes\n - received a total of 3u pRBCs & hct essentially stable (25-24)\n - urine clearing with CBI\n - blood Cx + to Vanc & Cefepime d/c'd\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 08:20 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:48 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: 35.8\nC (96.5\n HR: 56 (51 - 75) bpm\n BP: 100/60(70) {81/44(53) - 132/88(99)} mmHg\n RR: 14 (9 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 5 (4 - 10)mmHg\n Total In:\n 1,840 mL\n 705 mL\n PO:\n 150 mL\n 150 mL\n TF:\n IVF:\n 940 mL\n 555 mL\n Blood products:\n 750 mL\n Total out:\n 4,000 mL\n 900 mL\n Urine:\n 4,000 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,160 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 04:50 AM\n 12:39 PM\n 07:48 PM\n Hct\n 25.0\n 24.0\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n WBC Ct 5.8, Hgb 8.1, Hct 23.1, Plt 224\n Chem 10\n Imaging: TTE from \n The left atrium and right atrium are normal in cavity size. Left\n ventricular wall thickness, cavity size and regional/global systolic\n function are normal (LVEF >55%) The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve, but cannot be\n fully excluded due to suboptimal image quality. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. No masses or vegetations are seen on the mitral\n valve, but cannot be fully excluded due to suboptimal image quality.\n The tricuspid valve leaflets are mildly thickened. The estimated\n pulmonary artery systolic pressure is normal. There is no pericardial\n effusion.\n IMPRESSION: No vegetation or significant valvular regurgitation seen.\n Dilatation and hypokinesis of the right ventricle.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Microbiology:\n 8:10 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. PRELIMINARY SENSITIVITY.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STAPHYLOCOCCUS, COAGULASE NEGATIVE\n |\n ERYTHROMYCIN---------- R\n GENTAMICIN------------ S\n LEVOFLOXACIN---------- R\n RIFAMPIN-------------- S\n TETRACYCLINE---------- S\n VANCOMYCIN------------ S\n Blood Cx from & NGTD\n Urine Cx from NGTD\n C. diff pending \n Assessment and Plan\n 54 yo male with history of C2-C4 abscess with drainage complicated by\n quadriplegia was transferred to the for further management of \n bacteremia, sepsis resolving\n 1. Sepsis: resolving, likely etiology was bacteremia given gpcs in\n blood cultures, presumed source was erythematous PICC line now\n d/c'd. TTE showed no e/o vegetations. Other possible sources\n include sacral decubitus ulcer (site appears clean, without purulence)\n vs h/o epidural abscess, urine Cx NGTD, CXR clear.\n - f/u repeat blood Cx, continue surveillance Cx daily\n - continue vancomycin to cover (Ceftaz d/c'd on )\n - consider MRI L spine/TEE if repeat blood Cx are positive on Vanc\n 2. Acute Renal Failure: resolving, possible etiologies include\n post-renal obstruction from clots or pre-renal secondary to\n increased insensible losses / hypotension, or possibly progression to\n ATN given intermittent hypotension leading up to transfer. Creatinine\n trending down with IVF\n - renal US negative for hydro, did show clots within bladder\n - FeNa 2% suggestive of intrinsic process\n 3. Hematuria: pt developped hematuria & hct drop without clear h/o\n Foley trauma. Pt received 3u pRBCs, CBI initiated & Urology consulted,\n performed bedside hand flushes. Urine now running clear but hct has\n slowly trended down to 23 this am.\n - will transfuse with 1upRBCs, f/u post transfusion hct for goal >25\n - continue CBI for now\n - f/u urine cytology\n 4. Anemia: hct drop noted in setting of persistent hematuria and IVF\n hydration. Fe studies c/w anemia of chronic Dz, Vitamin B12 & folate\n WNL. Will f/u hct s/p transfusion with 1upRBCs today, goal hct >25\n - maintain two peripheral IVs and active type and cross\n 5. Decubitus Ulcer: Stage IV decubitus ulcer that appears clean and\n without evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms: pain medications were held initially\n given concern for altered mental status and lethargy. MS improved in\n am, BP trends down when sleeping, likely due to autonomic\n dysregulation.\n - continue home regimen of MS Contin & prn morphine\n - continue baclofen\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control: Regular insulin sliding scale\n Lines: 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Code status: Full code\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2117-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 408350, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 11:00 PM\n BLOOD CULTURED - At 04:50 AM\n - urology consulted for gross hematuria & hct drop, recommended CBI &\n hourly flushes\n - received a total of 3u pRBCs & hct essentially stable (25-24)\n - urine clearing with CBI\n - blood Cx + to Vanc & Cefepime d/c'd\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 08:20 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:48 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: 35.8\nC (96.5\n HR: 56 (51 - 75) bpm\n BP: 100/60(70) {81/44(53) - 132/88(99)} mmHg\n RR: 14 (9 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 5 (4 - 10)mmHg\n Total In:\n 1,840 mL\n 705 mL\n PO:\n 150 mL\n 150 mL\n TF:\n IVF:\n 940 mL\n 555 mL\n Blood products:\n 750 mL\n Total out:\n 4,000 mL\n 900 mL\n Urine:\n 4,000 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,160 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 04:50 AM\n 12:39 PM\n 07:48 PM\n Hct\n 25.0\n 24.0\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n WBC Ct 5.8, Hgb 8.1, Hct 23.1, Plt 224\n Na 140, K 3.5, Cl 109, Bicarb 24, BUN 19, Creatinine 0.8\n Ca 8.0, Mg 1.8, P 1.5\n Imaging: TTE from \n The left atrium and right atrium are normal in cavity size. Left\n ventricular wall thickness, cavity size and regional/global systolic\n function are normal (LVEF >55%) The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve, but cannot be\n fully excluded due to suboptimal image quality. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. No masses or vegetations are seen on the mitral\n valve, but cannot be fully excluded due to suboptimal image quality.\n The tricuspid valve leaflets are mildly thickened. The estimated\n pulmonary artery systolic pressure is normal. There is no pericardial\n effusion.\n IMPRESSION: No vegetation or significant valvular regurgitation seen.\n Dilatation and hypokinesis of the right ventricle.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Microbiology:\n 8:10 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. PRELIMINARY SENSITIVITY.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STAPHYLOCOCCUS, COAGULASE NEGATIVE\n |\n ERYTHROMYCIN---------- R\n GENTAMICIN------------ S\n LEVOFLOXACIN---------- R\n RIFAMPIN-------------- S\n TETRACYCLINE---------- S\n VANCOMYCIN------------ S\n Blood Cx from & NGTD\n Urine Cx from NGTD\n C. diff pending \n Assessment and Plan\n 54 yo male with history of C2-C4 abscess with drainage complicated by\n quadriplegia was transferred to the for further management of \n bacteremia, sepsis resolving\n 1. Sepsis: resolving, likely etiology was bacteremia given gpcs in\n blood cultures, presumed source was erythematous PICC line now\n d/c'd. TTE showed no e/o vegetations. Other possible sources\n include sacral decubitus ulcer (site appears clean, without purulence)\n vs h/o epidural abscess, urine Cx NGTD, CXR clear.\n - f/u repeat blood Cx, continue surveillance Cx daily\n - continue vancomycin to cover (Ceftaz d/c'd on )\n - consider MRI L spine/TEE if repeat blood Cx are positive on Vanc\n 2. Acute Renal Failure: resolving, possible etiologies include\n post-renal obstruction from clots or pre-renal secondary to\n increased insensible losses / hypotension, or possibly progression to\n ATN given intermittent hypotension leading up to transfer. Creatinine\n trending down with IVF\n - renal US negative for hydro, did show clots within bladder\n - FeNa 2% suggestive of intrinsic process\n 3. Hematuria: pt developped hematuria & hct drop without clear h/o\n Foley trauma. Pt received 3u pRBCs, CBI initiated & Urology consulted,\n performed bedside hand flushes. Urine now running clear but hct has\n slowly trended down to 23 this am.\n - will transfuse with 1upRBCs, f/u post transfusion hct for goal >25\n - continue CBI for now\n - f/u urine cytology\n 4. Anemia: hct drop noted in setting of persistent hematuria and IVF\n hydration. Fe studies c/w anemia of chronic Dz, Vitamin B12 & folate\n WNL. Will f/u hct s/p transfusion with 1upRBCs today, goal hct >25\n - maintain two peripheral IVs and active type and cross\n 5. Decubitus Ulcer: Stage IV decubitus ulcer that appears clean and\n without evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms: pain medications were held initially\n given concern for altered mental status and lethargy. MS improved in\n am, BP trends down when sleeping, likely due to autonomic\n dysregulation.\n - continue home regimen of MS Contin & prn morphine\n - continue baclofen\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control: Regular insulin sliding scale\n Lines: 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Code status: Full code\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2117-02-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 408351, "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 54 yr old, hx C2-C4 abscess complicated by quadriplegia\n 24 Hour Events:\n Liquid stools - sent for culture\n Transfused total of 4 units PRBC\n blood cultures positive for coag neg staph\n I/O probably not accurate given 4 L u/o\n Hematuria resolved on CBI\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 08:20 PM\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 Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Musculoskeletal: C/o muscle spasms, chronic back pain\n Flowsheet Data as of 10:30 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\nC (96.8\n HR: 55 (51 - 75) bpm\n BP: 105/73(79) {81/44(53) - 128/84(95)} mmHg\n RR: 15 (8 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 5 (4 - 10)mmHg\n Total In:\n 1,840 mL\n 1,176 mL\n PO:\n 150 mL\n 200 mL\n TF:\n IVF:\n 940 mL\n 601 mL\n Blood products:\n 750 mL\n 375 mL\n Total out:\n 4,000 mL\n 1,300 mL\n Urine:\n 4,000 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,160 mL\n -124 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n PERL, chest clear, S1S2 normal, abd nontender. PPP.\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.1 g/dL\n 224 K/uL\n 88 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 23.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:50 AM\n 12:39 PM\n 07:48 PM\n 04:29 AM\n WBC\n 8.3\n 5.8\n Hct\n 22.0\n 25.0\n 24.0\n 23.1\n Plt\n 217\n 224\n Cr\n 1.3\n 0.8\n Glucose\n 91\n 88\n Other labs: PT / PTT / INR:13.5/29.4/1.2, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:1.5 mg/dL\n Imaging: Echo - EF 55%, mild thickening, no vegetations but can't r/o\n completely with TTE.\n Microbiology: C diff pending\n cultures positive for coag neg staph\n Assessment and Plan\n Gram positive septicemia likely from infected PICC.\n 1. Coag negative staph sepsis - likely line sepsis from PICC with 4/4\n GPC. Continue vanco but switch to penicillin if sensitivities allow.\n TTE negative. If additional cultures positive, would do TEE. Otherwise,\n I think this is easily attributed to infected PICC.\n 2. Hematuria - improved. Cultures pending.\n 3. C2 quad - lives at . not vent dependent. Chronic pain.\n 4. Hx of pseudomonal UTI on .\n 5. Acute anemia - likely due to combination of hematuria and hydration.\n Seems to be stabilizing\n 6. Decubitus ulcers\n 7. Acute renal failure - resolved. etiology likley was post-renal\n secondary to obstruction with clots seen on ultrasound vs. pre-renal\n secondary hypotension.\n ICU Care\n Nutrition:\n Glycemic Control:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2117-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 408352, "text": "54 yo man w/ PMH of quadriplegia r/t C2-C4 abscess, and stage IV\n decubitus ulcer on coccyx. Pt recently had two extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria. Received 3 units PRBC\ns. Hematuria improved following manual\n bladder irrigation by urology and cont CBI.\n Sepsis without organ dysfunction\n Assessment:\n Pt currently with 3 negative blood cultures from , BP: hypotensive to\n the high 80s at times while sleeping Normotensive while awake did\n receive some fluid at arrival to ICU, no FB for over 24hr has never\n required pressors, afebrile\n Action:\n Monitoring BP, monitoring temp, treating with vanco\n Response:\n Negative cultures as noted above, source of infection unknown\n Plan:\n Reculture if temp spikes, continue vanco tx, will requirement PICC\n placement for antibiotics ordered as routine\n Hematuria\n Assessment:\n Pt with much inproved urine quality, urine clear yellow with no clots,\n CBI has slowed markedly, hct stable at 23.1 pt with known hx of chronic\n anemia, has received 4UPRBC since adm to MICU\n Action:\n Continuing CBI at this time per urology, titirating to clear urine as\n noted above, received 1 UPRBC for am hct of 23.1, post transfusion hct\n drawn\n Response:\n Hematuria resolved\n Plan:\n Continue CBI, urology to f/u, plan to place suprapubic cath by Dr.\n in wks as an outpt procedure\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with chronic pain issues, reporting generalized pain at rest, at\n times reporting pain at a , positional discomfort at times\n Action:\n Restarted home pain medications, pt receiving MS and\n Baclofen, Baclofen dose increased today per pt request, also receiving\n prn Tylenol for relenting discomfort, repositioning q2hr, pt very\n sensitive to any stimulation and movement\n Response:\n Pt continues to report pain levels high at times but is also reporting\n some relief with adm of meds, discomfort relieved with repositioning,\n continues to have spasms with light senation ie. Movement of top sheet\n Plan:\n Continue to assess pain, ?readjust medication for better pain control,\n reconcile with home meds prior to d/c to rehab\n Impaired Skin Integrity\n Assessment:\n Pt with admitted with stage IV as noted above, dsg d+I, wound care\n following see recs for dsg changes, wound is approximately 10cmx10cm\n with tunneling, wound base red/white, minimal drainage, on kinair bed\n Action:\n Daily dsg changes, changing dsg more frequently at times d/t frequent\n BMs, pt with 6 BMs in the last 24hrs\n Response:\n Unknown\n Plan:\n Continue dailly dsg changes, wound care to follow, pt is followed as an\n outpatient by plastics, q2hr turns, kinair bed\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 97.7 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Unknown;\n Precautions: Contact\n PMH: Hepatitis\n CV-PMH:\n Additional history: Quadriplegia r/t C2-C4 abcess .\n Stage IV Sacral Decub\n Muscle Spasms/Chronic Pain\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\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 None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 705 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:50 AM\n Potassium:\n 3.2 mEq/L\n 04:50 AM\n Chloride:\n 104 mEq/L\n 04:50 AM\n CO2:\n 24 mEq/L\n 04:50 AM\n BUN:\n 31 mg/dL\n 04:50 AM\n Creatinine:\n 1.3 mg/dL\n 04:50 AM\n Glucose:\n 91 mg/dL\n 04:50 AM\n Hematocrit:\n 24.0 %\n 07:48 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": "Physician ", "chartdate": "2117-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 408353, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 11:00 PM\n BLOOD CULTURED - At 04:50 AM\n - urology consulted for gross hematuria & hct drop, recommended CBI &\n hourly flushes\n - received a total of 3u pRBCs & hct essentially stable (25-24)\n - urine clearing with CBI\n - blood Cx + coag neg staph to \n Pt feeling much better this am though still c/o some chronic pain.\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 08:20 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 05:48 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: 35.8\nC (96.5\n HR: 56 (51 - 75) bpm\n BP: 100/60(70) {81/44(53) - 132/88(99)} mmHg\n RR: 14 (9 - 17) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 5 (4 - 10)mmHg\n Total In:\n 1,840 mL\n 705 mL\n PO:\n 150 mL\n 150 mL\n TF:\n IVF:\n 940 mL\n 555 mL\n Blood products:\n 750 mL\n Total out:\n 4,000 mL\n 900 mL\n Urine:\n 4,000 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,160 mL\n -195 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN: NAD, comfortable\n CV: RRR no m/r/g\n RESP: CTAB no w/r\n ABD: soft, NT/ND, NABS\n Extr: boots in place, no c/c/e\n Sacrum not seen today, stage IV decub per nursing\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 04:29AM\n 5.8\n 2.65*\n 8.1*\n 23.1*\n 87\n 30.7\n 35.2*\n 15.3\n 224\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [2] 04:29AM\n 88\n 19\n 0.8\n 140\n 3.5\n 109*\n 24\n 11\n 04:50 AM\n 12:39 PM\n 07:48 PM\n Hct\n 25.0\n 24.0\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n WBC Ct 5.8, Hgb 8.1, Hct 23.1, Plt 224\n Na 140, K 3.5, Cl 109, Bicarb 24, BUN 19, Creatinine 0.8\n Ca 8.0, Mg 1.8, P 1.5\n Imaging: TTE from \n The left atrium and right atrium are normal in cavity size. Left\n ventricular wall thickness, cavity size and regional/global systolic\n function are normal (LVEF >55%) The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No masses or vegetations are seen on the aortic valve, but cannot be\n fully excluded due to suboptimal image quality. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. No masses or vegetations are seen on the mitral\n valve, but cannot be fully excluded due to suboptimal image quality.\n The tricuspid valve leaflets are mildly thickened. The estimated\n pulmonary artery systolic pressure is normal. There is no pericardial\n effusion.\n IMPRESSION: No vegetation or significant valvular regurgitation seen.\n Dilatation and hypokinesis of the right ventricle.\n If clinically suggested, the absence of a vegetation by 2D\n echocardiography does not exclude endocarditis.\n Microbiology:\n 8:10 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. PRELIMINARY SENSITIVITY.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STAPHYLOCOCCUS, COAGULASE NEGATIVE\n |\n ERYTHROMYCIN---------- R\n GENTAMICIN------------ S\n LEVOFLOXACIN---------- R\n RIFAMPIN-------------- S\n TETRACYCLINE---------- S\n VANCOMYCIN------------ S\n Blood Cx from & NGTD\n Urine Cx from NGTD\n C. diff pending \n Assessment and Plan\n 54 yo male with history of C2-C4 abscess c/b quadriplegia was\n transferred to the for management of coag negative staph\n bacteremia & sepsis, now resolving\n 1. Sepsis: resolved, likely etiology was bacteremia given gpcs in\n blood cultures, presumed source was erythematous PICC line now\n d/c'd. TTE showed no e/o vegetations. Other possible sources\n include sacral decubitus ulcer (site appears clean, without purulence)\n vs recurrence epidural abscess, urine Cx NGTD, CXR clear. Surveillance\n Cx are NGTD\n - f/u repeat blood Cx, will CIS\n - continue vancomycin to cover coag neg staph (t/b with lab for further\n sensitivities)\n - consider MRI L spine/TEE if repeat blood Cx are positive on \n - PICC line request for long term ABx\n 2. Acute Renal Failure: resolved, possible etiologies include\n post-renal obstruction from clots or pre-renal secondary to\n dehydration or intermittent hypotension leading to transfer.\n Creatinine trending down to normal with IVF . Renal US negative for\n hydronephrosis, did show clots within bladder. Urine clear s/p CBI\n - avoid nephrotoxins & monitor creatinine daily\n 3. Hematuria: pt developed acute hematuria & hct drop without clear h/o\n Foley trauma. Pt received 3u pRBCs, CBI initiated & Urology consulted,\n performed bedside hand flushes. Urine now running clear but hct has\n slowly trended down to 23 this am.\n - will transfuse with 1upRBCs, f/u post transfusion hct for goal >25\n - continue CBI for now\n - f/u urine cytology\n - urology recommending f/u with Dr. in 4-6wks for suprapubic\n cath placement\n 4. Anemia: hct drop noted in setting of persistent hematuria and IVF\n hydration. Fe studies c/w anemia of chronic Dz, Vitamin B12 & folate\n WNL.\n - f/u hct s/p transfusion with 1upRBCs today, goal hct >25\n 5. Decubitus Ulcer: Stage IV decubitus ulcer that appears clean and\n without evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms: pain medications were held initially\n given concern for altered mental status and lethargy. MS improved in\n am, BP trends down when sleeping, likely due to autonomic\n dysregulation.\n - continue home regimen of MS Contin & prn morphine\n - increased baclofen to\n of regular home regimen, achieved better\n control of pain/spasm\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control: Regular insulin sliding scale\n Lines: 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Code status: Full code\n Disposition: call out to floor\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_17%22);\n" }, { "category": "Nursing", "chartdate": "2117-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408354, "text": "Sepsis without organ dysfunction\n Assessment:\n Pt currently with 3 negative blood cultures from , BP: hypotensive to\n the high 80s at times while sleeping Normotensive while awake did\n receive some fluid at arrival to ICU, no FB for over 24hr has never\n required pressors, afebrile\n Action:\n Monitoring BP, monitoring temp, treating with vanco\n Response:\n Negative cultures as noted above, source of infection unknown\n Plan:\n Reculture if temp spikes, continue vanco tx, will requirement PICC\n placement for antibiotics ordered as routine\n Hematuria\n Assessment:\n Pt with much inproved urine quality, urine clear yellow with no clots,\n CBI has slowed markedly, hct stable at 23.1 pt with known hx of chronic\n anemia, has received 4UPRBC since adm to MICU\n Action:\n Continuing CBI at this time per urology, titirating to clear urine as\n noted above, received 1 UPRBC for am hct of 23.1, post transfusion hct\n drawn\n Response:\n Hematuria resolved, repeat hct stable\n Plan:\n Continue CBI until , urology to f/u, plan to place suprapubic cath\n by Dr. in wks as an outpt procedure\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with chronic pain issues, reporting generalized pain at rest, at\n times reporting pain at a , positional discomfort at times\n Action:\n Restarted home pain medications, pt receiving MS and\n Baclofen, Baclofen dose increased today per pt request, also receiving\n prn Tylenol for relenting discomfort, repositioning q2hr, pt very\n sensitive to any stimulation and movement, ordered PRN po IR morphine\n as well\n Response:\n Pt continues to report pain levels high at times but is also reporting\n some relief with adm of meds, discomfort relieved with repositioning,\n continues to have spasms with light senation ie. Movement of top sheet,\n IR morphine with minimal effect, pt able to rest comfortably at times\n Plan:\n Continue to assess pain, ?readjust medication for better pain control\n Impaired Skin Integrity\n Assessment:\n Pt with admitted with stage IV as noted above, dsg d+I, wound care\n following see recs for dsg changes, wound is approximately 10cmx10cm\n with tunneling, wound base red/white, minimal drainage, on kinair bed,\n pt with healing ulcers on heels kerlex intact\n Action:\n Daily dsg changes, changing dsg more frequently at times d/t frequent\n BMs, pt with 6 BMs in the last 24hrs\n Response:\n Unknown\n Plan:\n Continue daily dsg changes, wound care to follow, pt is followed as an\n outpatient by plastics, q2hr turns, kinair bed\n" }, { "category": "Nursing", "chartdate": "2117-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 408355, "text": "54 yo man w/ PMH of quadriplegia r/t C2-C4 abscess, and stage IV\n decubitus ulcer on coccyx. Pt recently had two extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria. Received 3 units PRBC\ns. Hematuria improved following manual\n bladder irrigation by urology and cont CBI.\n Sepsis without organ dysfunction\n Assessment:\n Pt currently with 3 negative blood cultures from , BP: hypotensive to\n the high 80s at times while sleeping Normotensive while awake did\n receive some fluid at arrival to ICU, no FB for over 24hr has never\n required pressors, afebrile\n Action:\n Monitoring BP, monitoring temp, treating with vanco\n Response:\n Negative cultures as noted above, source of infection unknown\n Plan:\n Reculture if temp spikes, continue vanco tx, will requirement PICC\n placement for antibiotics ordered as routine\n Hematuria\n Assessment:\n Pt with much inproved urine quality, urine clear yellow with no clots,\n CBI stiopped at tonight. Hct stable at 23.1 pt with known hx of\n chronic anemia, has received 4UPRBC since adm to MICU\n Action:\n Continuing CBI at this time per urology, titirating to clear urine as\n noted above, received 1 UPRBC for am hct of 23.1, post transfusion hct\n drawn\n Response:\n Hematuria resolved\n Plan:\n Monitor u/o closely, Urology to f/u, plan to place suprapubic cath by\n Dr. in wks as an outpt procedure\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with chronic pain issues, reporting generalized pain at rest, at\n times reporting pain at a , positional discomfort at times\n Action:\n Restarted home pain medications, pt receiving MS and\n Baclofen, Baclofen dose increased today per pt request, also receiving\n prn Tylenol for relenting discomfort, repositioning q2hr, pt very\n sensitive to any stimulation and movement\n Response:\n Pt continues to report pain levels high at times but is also reporting\n some relief with adm of meds, discomfort relieved with repositioning,\n continues to have spasms with light senation ie. Movement of top sheet\n Plan:\n Continue to assess pain, ?readjust medication for better pain control,\n reconcile with home meds prior to d/c to rehab\n Impaired Skin Integrity\n Assessment:\n Pt with admitted with stage IV as noted above, dsg d+I, wound care\n following see recs for dsg changes, wound is approximately 10cmx10cm\n with tunneling, wound base red/white, minimal drainage, on kinair bed\n Action:\n Daily dsg changes, changing dsg more frequently at times d/t frequent\n BMs, pt with 6 BMs in the last 24hrs\n Response:\n Unknown\n Plan:\n Continue dailly dsg changes, wound care to follow, pt is followed as an\n outpatient by plastics, q2hr turns, kinair bed\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 97.7 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Unknown;\n Precautions: Contact\n PMH: Hepatitis\n CV-PMH:\n Additional history: Quadriplegia r/t C2-C4 abcess .\n Stage IV Sacral Decub\n Muscle Spasms/Chronic Pain\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\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 None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 705 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:50 AM\n Potassium:\n 3.2 mEq/L\n 04:50 AM\n Chloride:\n 104 mEq/L\n 04:50 AM\n CO2:\n 24 mEq/L\n 04:50 AM\n BUN:\n 31 mg/dL\n 04:50 AM\n Creatinine:\n 1.3 mg/dL\n 04:50 AM\n Glucose:\n 91 mg/dL\n 04:50 AM\n Hematocrit:\n 24.0 %\n 07:48 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": "2117-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 408356, "text": "54 yo man w/ PMH of quadriplegia r/t C2-C4 abscess, and stage IV\n decubitus ulcer on coccyx. Pt recently had two extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria. Received 3 units PRBC\ns. Hematuria improved following manual\n bladder irrigation by urology and cont CBI.\n Sepsis without organ dysfunction\n Assessment:\n Pt currently with 3 negative blood cultures from , BP: hypotensive to\n the high 80s at times while sleeping Normotensive while awake did\n receive some fluid at arrival to ICU, no FB for over 24hr has never\n required pressors, afebrile\n Action:\n Monitoring BP, monitoring temp, treating with vanco\n Response:\n Negative cultures as noted above, source of infection unknown\n Plan:\n Reculture if temp spikes, continue vanco tx, will requirement PICC\n placement for antibiotics ordered as routine\n Hematuria\n Assessment:\n Pt with much inproved urine quality, urine clear yellow with no clots,\n CBI stiopped at tonight. Hct stable at 23.1 pt with known hx of\n chronic anemia, has received 4UPRBC since adm to MICU\n Action:\n Continuing CBI at this time per urology, titirating to clear urine as\n noted above, received 1 UPRBC for am hct of 23.1, post transfusion hct\n drawn\n Response:\n Hematuria resolved\n Plan:\n Monitor u/o closely, Urology to f/u, plan to place suprapubic cath by\n Dr. in wks as an outpt procedure\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with chronic pain issues, reporting generalized pain at rest, at\n times reporting pain at a , positional discomfort at times\n Action:\n Restarted home pain medications, pt receiving MS and\n Baclofen, Baclofen dose increased today per pt request, also receiving\n prn Tylenol for relenting discomfort, repositioning q2hr, pt very\n sensitive to any stimulation and movement\n Response:\n Pt continues to report pain levels high at times but is also reporting\n some relief with adm of meds, discomfort relieved with repositioning,\n continues to have spasms with light senation ie. Movement of top sheet\n Plan:\n Continue to assess pain, ?readjust medication for better pain control,\n reconcile with home meds prior to d/c to rehab\n Impaired Skin Integrity\n Assessment:\n Pt with admitted with stage IV as noted above, dsg d+I, wound care\n following see recs for dsg changes, wound is approximately 10cmx10cm\n with tunneling, wound base red/white, minimal drainage, on kinair bed\n Action:\n Daily dsg changes, changing dsg more frequently at times d/t frequent\n BMs, pt with 6 BMs in the last 24hrs\n Response:\n Unknown\n Plan:\n Continue dailly dsg changes, wound care to follow, pt is followed as an\n outpatient by plastics, q2hr turns, kinair bed\n Demographics\n Attending MD:\n , \n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 97.7 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Unknown;\n Precautions: Contact\n PMH: Hepatitis\n CV-PMH:\n Additional history: Quadriplegia r/t C2-C4 abcess .\n Stage IV Sacral Decub\n Muscle Spasms/Chronic Pain\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\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 None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 705 mL\n 24h total out:\n 900 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:50 AM\n Potassium:\n 3.2 mEq/L\n 04:50 AM\n Chloride:\n 104 mEq/L\n 04:50 AM\n CO2:\n 24 mEq/L\n 04:50 AM\n BUN:\n 31 mg/dL\n 04:50 AM\n Creatinine:\n 1.3 mg/dL\n 04:50 AM\n Glucose:\n 91 mg/dL\n 04:50 AM\n Hematocrit:\n 24.0 %\n 07:48 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": "2117-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408346, "text": "Sepsis without organ dysfunction\n Assessment:\n SBP 90-120 when awake, dropped to 80\ns systolic when sleeping\n Afebrile, HR stable.\n Fluid balance -2.1 L at MN\n Action:\n Received 500cc NS bolus \n Received vanco dose \n Stool sample sent for c-diff .\n Response:\n Pts BP improved following NS bolus\n MAP >60\n Remains stable, afebrile.\n Plan:\n Cont to monitor pt for hypotension, fever.\n f/u w/ blood cultures.\n Hematuria\n Assessment:\n Urine remains light pink and clear.\n No clots noted.\n HCT 24 .\n Action:\n Conts on CBI via 3-way cath titrated to clear.\n No blood products .\n Response:\n Conts clear pink urine, no clots.\n Plan:\n Cont CBI\n Recheck HCT w/ AM labs\n Urology following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o throbbing generalized pain , noted mostly in\n extremities.\n Pain increases w/ positioning\n Action:\n Received scheduled morphine dose, and prn Tylenol .\n Deep breathing done when turning.\n Response:\n Pt stated relief of pain following analgesia\n Plan:\n Cont to monitor pts pain level\n Provide meds as ordered and cont deep breathing during turning.\n Impaired Skin Integrity\n Assessment:\n Pt has stage IV decub on coccyx\n Action:\n Dressing was soiled and changed per wound care recs.\n Repositioned q2 hours side to side.\n Waffle boots remain on bilat feet.\n Response:\n Dressing remains dry and intact\n Plan:\n Cont to monitor dressing status, and change daily per recs and prn.\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408345, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting pain throughout the shift, unable to clearly identify\n source of pain, screaming out with discomfort with moving of linens and\n minimal activity, reporting pain at 10/10\n Action:\n Restarting home pain meds today, receiving PO MS Contin and Baclofen\n Response:\n Pt continues to report constant pain, tolerating well, pain especially\n with activity encouraging pt to breath\n Plan:\n Continue to monitor pain, ?increase pain meds if unable to control with\n home meds, ?chronic pain consult\n Impaired Skin Integrity\n Assessment:\n Pt with stage IV decub on coccyx, healed ulcers on heels bilat\n Action:\n Dsg changed on coccyx x2 per wound care recs, see wound care note for\n dsg recommendations, kerlex clean and intact on heels bilat, position\n change q2hr, pt with waffle boots on feet\n Response:\n Unknown\n Plan:\n Continue to monitor wounds, daily dsg changes per wound care\n Sepsis without organ dysfunction\n Assessment:\n Pt bp wnl throughout the day, see flowsheet for objective data\n Action:\n Blood cultures sent\n Response:\n Unknown\n Plan:\n Dailly blood cultures, continue to monitor pt for hypotension, treat\n with IVF or blood products as directed\n Problem - Description In Comments\n Assessment:\n Hematuria, pt continues to have pink-red urine per CBI, am hct with\n drop in the setting of fluid recessitation\n Action:\n CBI titrating to clear urine, urology in to consult, urology hand\n irrigating pt for many clots, initiated hand irrigation hourly, given\n one unit of PRBC, repeat hct obtained\n Response:\n Pt urine improving throughout the shift, last hand irrigation with no\n clots noted\n Plan:\n Continue CBI, d/c hand irrigation, continue to follow hct, ?if hct\n stable and urine appears clear c/o in am\n" }, { "category": "Nutrition", "chartdate": "2117-02-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 408342, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 54 year old male transferred from floor d/t hypotension and change in\n MS found with sepsis, infected PICC line. Patient has history of\n quadriplegia, abscesses from C2-C4, stage IV decubitus ulcer on coccyx,\n fever of unknown origin, hepatitis B and C. Patient is currently NPO.\n Meds include Multivitamin, Vitamin B, Vitamin C, Zinc sulfate. Please\n advance diet as tolerated when medically possible. If unable to\n advance, consider tube feedings as patient at high nutritional risk d/t\n stage IV ulcer, pmhx.\n 11:25\n" }, { "category": "Physician ", "chartdate": "2117-02-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 408334, "text": "Chief Complaint: transfer for hypotension and altered mental\n HPI:\n 54 yo male with history of quadriplegia s/p C2-C4 abscess and stage 4\n decubitus ulcer was transferred from the floor to the with\n hypotension and altered mental status in the setting of gram positive\n bacteremia. Patient was delirious at the time of transfer, and history\n was obtained from patient, patient's family, and chart review.\n Patient was previously admitted to for two prolonged\n hospitalizations from 1/10-31/08 and from /08 with fever.\n During his initial admission in , he was treated for a\n pseudomonal UTI and pseudomonal bacteremia with double coverage with\n ceftazidime and cipro for 2 weeks. He was then discharged to \n Rehab at the end of ; however his stay at rehab was complicated\n by daily fevers and delirium for which he was re-admitted to for\n further evaluation. Blood cultures taken at rehab were notable for 2\n separate blood cultures positive for coag negative staph. Given the two\n separate positive blood cultures, patient completed a 2 week course of\n vancomycin. No additional sources of fever were found during his\n work-up during this second admission. Patient was then discharged to\n rehab on .\n The on , he was found to have increased hematuria with blood\n surrounding his Foley, and he was sent to ED for further\n evaluation. In the ED, his vital signs were notable for a fever to\n 103.7 with systolic blood pressures of 110-130. He received vancomycin\n and zosyn, and was admitted to the floor overnight into . Over\n the course of the day on , patient was noted to be increasingly\n lethargic and was then triggered for BP of 80s/60s. Repeat labs drawn\n at that time were notable for a hematocrit drop from 25 to 19. He was\n then transferred to the ICU for closer monitoring, placement of central\n access, and further evaluation of sepsis.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 11:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. C2-c4 abscess c/b quadriplegia\n 2. Stage 4 Sacral Decubitus Ulcer\n 3. Fever of Unknown Origin\n 4. Chronic Muscle Spasms and Chronic Pain\n 5. Sacral decub ulcers\n 6. Hepatitis B and Hepatitis C\n Noncontributory\n Occupation: Previously self-employed as a paint contractor prior to\n automobile accident in and abscess in 8\n Drugs: previously used cocaine and IV heroin. Was previously on\n methadone maintenance\n Tobacco: did not assess\n Alcohol: has been sober x > 20 years\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Genitourinary: Foley, hematuria\n Musculoskeletal: Joint pain, Chronic Pain and Muscle Spasms\n Flowsheet Data as of 01:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 60 (54 - 66) bpm\n BP: 122/74(84) {80/39(49) - 122/74(84)} mmHg\n RR: 7 (7 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,185 mL\n 83 mL\n PO:\n TF:\n IVF:\n 810 mL\n 13 mL\n Blood products:\n 375 mL\n 70 mL\n Total out:\n 2,500 mL\n 0 mL\n Urine:\n 2,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,315 mL\n 83 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\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, Paradoxical), (Breath\n Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Unable to stand, quadriplegic\n Skin: Stage 4 sacral decubitus ulcer approximately 8x6cm in size with\n clean and dry edges, no evidence of purulent drainage or fluctuance\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person , Movement: Not assessed, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ASSESSMENT:\n 54 yo male with history of C2-C4 abscess with drainage complicated by\n quadriplegia was transferred to the for further management of\n severe sepsis.\n PLAN:\n 1. Severe Sepsis\n Patient was transferred from the floor with evidence of sepsis\n (temperature to 103.7 on admission and elevated WBC) and end organ\n dysfunction given his altered mental status. Most likely source of his\n sepsis is bacteremia given gram positive cocci in blood cultures.\n Etiology of his bacteremia is likely from PICC line that has been\n pulled, although an additional possibility includes sacral decubitus\n ulcer (although site appears clean and without purulent drainage).\n Additional sources include genitourinary source given hematuria. No\n additional evidence for pulmonary source given lungs relatively clear\n on exam, O2 sat appropriate on room air, and unremarkable CXR.\n - follow-up blood and urine cultures\n - check CXR\n - fluid resuscitate with blood products and IVF boluses prn for goal\n MAP > 65\n - place central line for possible initiation of pressors\n - start broad spectrum antibiotics with vancomycin to cover MRSA and\n ceftazidime for pseudomonas coverage; titrate antibiotics as needed\n pending blood cultures\n - check AM cortisol\n - consider re-ordering MRI L spine if increased suspicion for\n osteomyelitis; will hold off on ordering now given acute renal failure\n 2. Acute Renal Failure\n Etiology appears most likely either post-renal secondary to obstruction\n secondary to clots, pre-renal secondary to increased insensible losses\n / hypotension, or possibly progression to ATN given intermittent\n hypotension leading up to transfer.\n - send FE urea\n - follow-up final read of renal US\n 3. Hematuria\n Unclear etiology for sudden development of hematuria given no clear\n history for Foley trauma.\n - continue CBI\n - send urine cytology\n - consider urology consult if hematuria persists or if creatinine\n worsens\n 4. Anemia\n Patient with hematocrit decrease in the setting of persistent hematuria\n and IVF hydration. Differential includes blood loss secondary to\n hematuria.\n - check iron studies, vitamin B12, folate, and reticulocyte count\n - guiac all stools\n - transfuse 2 units pRBCs given concern for active bleeding\n - follow-up post-transfusion hct and transfuse if hct does not\n appropriately bump\n - maintain two peripheral IVs and active type and cross\n 5. Decubitus Ulcer\n Patient with Stage IV decubitus ulcer that appears clean and without\n evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms\n Patient with chronic pain and muscle spasms. Pain medications were held\n immediately prior to transfer given concern for altered mental status\n and lethargy. Blood pressure and mental status are now slightly\n improved.\n - continue patient's MS Contin\n - will re-assess mental status in the AM and consider adding back prn\n morphine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408335, "text": "54 y\n Sepsis without organ dysfunction\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 Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408336, "text": "54 yo man w/ PMH of quadriplegia r/t to MVA, C2-C4 abscess, and stage\n IV decubitus ulcer on coccyx. Pt recently had two extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria.\n Sepsis without organ dysfunction\n Assessment:\n Upon arrival to unit SBP was 78-85, HR stable.\n Pt was lethargic, arousable to stimulation.\n 02 sats 97-100 on room air.\n Pt was afebrile\n HCT drop from 25 to 19.\n Action:\n Received 500cc NS bolus\n Received 2 units PRBC\n R IJ triple lumen cath inserted.\n Received scheduled doses of vanco and ceftazidime overnight.\n Response:\n SBP improved to 90-105 following IVF and PRBC\n Pt became more alert following improvement in BP, disoriented to place.\n CXR confirmed placement of central line.\n Plan:\n Cont to monitor hemodynamics.\n Cont to monitor labs, blood and urine cx\n Cont to monitor pts orientation/mental status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues CBI\n Urine red/pink w/ clots.\n BUN 38/ Cr 2.1\n UO adequate.\n Action:\n Cont CBI, titrated to clear urine.\n Response:\n Urine remains pink w/ clots on CBI\n Plan:\n Cont CBI\n Cont to monitor urine output, renal function labs.\n Impaired Skin Integrity\n Assessment:\n Pt has stage IV decubitus ulcer on cocccyx\n Action:\n Dressing changed upon arrival to unit per wound care RN\ns recs.\n Pt on kinair bed, turned and repositioned off back\n Response:\n Dressing remains dry and intact.\n Plan:\n Dressing to be changed tomorrow.\n Wound care RN following.\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408337, "text": "54 yo man w/ PMH of quadriplegia r/t to MVA, C2-C4 abscess, and stage\n IV decubitus ulcer on coccyx. Pt recently had two extended\n hospitalizations at . Pt was sent to ED from NH on w/ fever\n and hematuria. Pt had pos blood cultures (gram pos) at NH. Pt started\n on CBI in ED. Admitted to medical floor on where pt triggered for\n increased lethargy, hypotension, and cont hematuria w/ HCT drop from 25\n to 19. pt was transferred to M/SICU for further mgt of sepsis and\n hematuria.\n Sepsis without organ dysfunction\n Assessment:\n Upon arrival to unit SBP was 78-85, HR stable.\n Pt was lethargic, arousable to stimulation.\n 02 sats 97-100 on room air.\n Pt was afebrile\n HCT drop from 25 to 19.\n Action:\n Received 500cc NS bolus\n Received 2 units PRBC\n R IJ triple lumen cath inserted.\n Received scheduled doses of vanco and ceftazidime .\n Response:\n SBP improved to 90-105 following IVF and PRBC\n Pt became more alert following improvement in BP, disoriented to place.\n CXR confirmed placement of central line.\n Plan:\n Cont to monitor hemodynamics.\n Cont to monitor labs, blood and urine cx\n Cont to monitor pts orientation/mental status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues CBI\n Urine red/pink w/ clots.\n BUN 38/ Cr 2.1\n UO adequate.\n Action:\n Cont CBI, titrated to clear urine.\n Response:\n Urine remains pink w/ clots on CBI\n Plan:\n Cont CBI\n Cont to monitor urine output, renal function labs.\n Impaired Skin Integrity\n Assessment:\n Pt has stage IV decubitus ulcer on cocccyx\n Action:\n Dressing changed upon arrival to unit per wound care RN\ns recs.\n Pt on kinair bed, turned and repositioned off back\n Response:\n Dressing remains dry and intact.\n Plan:\n Dressing to be changed tomorrow.\n Wound care RN following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of pain in legs\n Pt described as severe muscle cramping\n Pain increased w/ minimal movement of legs.\n Action:\n Received 650mg PO Tylenol\n Received 30mg MS .\n Response:\n Pt stated pain decreased to following pain meds.\n Sleeping comfortably at present.\n Plan:\n Cont to monitor pts pain level.\n Provide analgesia per order.\n" }, { "category": "Physician ", "chartdate": "2117-02-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 408338, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:22 PM\n - transfused 2 units pRBCs, ordered for 1 more\n History obtained from Family / Medical records\n Allergies:\n History obtained from Family / Medical Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 11:30 PM\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 Musculoskeletal: leg pain and cramping\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: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 57 (54 - 66) bpm\n BP: 94/63(70) {80/39(49) - 122/74(84)} mmHg\n RR: 9 (7 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 7 (3 - 7)mmHg\n Total In:\n 1,185 mL\n 946 mL\n PO:\n TF:\n IVF:\n 810 mL\n 571 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 2,500 mL\n 800 mL\n Urine:\n 2,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,315 mL\n 146 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\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, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 217 K/uL\n 7.7 g/dL\n 91 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 31 mg/dL\n 104 mEq/L\n 133 mEq/L\n 22.0 %\n 8.3 K/uL\n [image002.jpg]\n 04:50 AM\n WBC\n 8.3\n Hct\n 22.0\n Plt\n 217\n Cr\n 1.3\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: Renal US - No hydronephrosis. No evidence of bladder mass,\n partially\n distended bladder with internal clots.\n Microbiology: - Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS AEROBIC BOTTLE .\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n Assessment and Plan\n 54 yo male with history of C2-C4 abscess with drainage complicated by\n quadriplegia was transferred to the for further management of\n severe sepsis.\n PLAN:\n 1. Severe Sepsis\n Patient was transferred from the floor with evidence of sepsis\n (temperature to 103.7 on admission and elevated WBC) and end organ\n dysfunction given his altered mental status. Most likely source of his\n sepsis is bacteremia given gram positive cocci in blood cultures.\n Etiology of his bacteremia is likely from PICC line that has been\n pulled, although an additional possibility includes sacral decubitus\n ulcer (although site appears clean and without purulent drainage).\n Additional sources include genitourinary source given hematuria. No\n additional evidence for pulmonary source given lungs relatively clear\n on exam, O2 sat appropriate on room air, and unremarkable CXR.\n - follow-up blood and urine cultures - on contact precautions \n speciation of gram + cocci\n - CXR- neg for acute cardiopulm process\n - fluid resuscitate with blood products and IVF boluses prn for goal\n MAP > 65\n - placed central line for possible initiation of pressors\n - start broad spectrum antibiotics with vancomycin to cover MRSA and\n ceftazidime for pseudomonas coverage; titrate antibiotics as needed\n pending blood cultures\n - check AM cortisol\n - consider re-ordering MRI L spine if increased suspicion for\n osteomyelitis; will hold off on ordering now given acute renal failure\n 2. Acute Renal Failure\n Etiology appears most likely either post-renal secondary to obstruction\n secondary to clots, pre-renal secondary to increased insensible losses\n / hypotension, or possibly progression to ATN given intermittent\n hypotension leading up to transfer.\n - send FE urea\n - renal US negative for hydro, did show clots within bladder\n - FeNa 2% suggestive of intrinsic process\n - spin urine today to evaluate for casts\n 3. Hematuria\n Unclear etiology for sudden development of hematuria given no clear\n history for Foley trauma. On CBI with persistently bloody urine, in\n interval when CBI bags being changed, urine noted to be frankly bloody\n by nursing\n - continue CBI\n - send urine cytology\n - consider urology consult if hematuria persists or if creatinine\n worsens\n - continue to transfuse for HCT>25\n 4. Anemia\n Patient with hematocrit decrease in the setting of persistent hematuria\n and IVF hydration. Differential includes blood loss secondary to\n hematuria.\n - check iron studies, vitamin B12, folate, and reticulocyte count\n - guaiac all stools\n - transfused 2 units pRBCs given concern for active bleeding, will\n continue to transfuse for HCT>25\n - check HCT q4h\n - maintain two peripheral IVs and active type and cross\n 5. Decubitus Ulcer\n Patient with Stage IV decubitus ulcer that appears clean and without\n evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms\n Patient with chronic pain and muscle spasms. Pain medications were held\n immediately prior to transfer given concern for altered mental status\n and lethargy. Blood pressure and mental status are now slightly\n improved.\n - continue patient's MS Contin\n - continue baclofen\n - will re-assess mental status in the AM and consider adding back prn\n morphine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 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:\n" }, { "category": "Physician ", "chartdate": "2117-02-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 408339, "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 See Dr note in chart.\n 54 yr old male with C2 quadriplegia. Recent treatment for pseudomonal\n UTI and bacteremia.\n Admitted from rehab recently for delerium and fevers.\n Returned with hematuria, fever 103.2, drop in hct, 4/4 bottles positive\n for GPC.\n Subsequently BP decreased to 80 systolic\n 24 Hour Events:\n Central line inserted. Transfused 2 units PRBC.\n On CBI with frank bloody urethral discharge.\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 11:30 PM\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 Musculoskeletal: chronic back pain\n Flowsheet Data as of 09:11 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: 57 (54 - 66) bpm\n BP: 94/63(70) {80/39(49) - 122/74(84)} mmHg\n RR: 9 (7 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 7 (3 - 7)mmHg\n Total In:\n 1,185 mL\n 963 mL\n PO:\n TF:\n IVF:\n 810 mL\n 588 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 2,500 mL\n 800 mL\n Urine:\n 2,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,315 mL\n 163 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, interm confused\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) 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: (Breath Sounds: Clear : ant but distant breath\n sounds)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, decub ulcer\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, , ED, Movement: Not assessed,\n Tone: Not assessed, quadriplegic\n Labs / Radiology\n 7.7 g/dL\n 217 K/uL\n 91 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 31 mg/dL\n 104 mEq/L\n 133 mEq/L\n 22.0 %\n 8.3 K/uL\n [image002.jpg]\n 04:50 AM\n WBC\n 8.3\n Hct\n 22.0\n Plt\n 217\n Cr\n 1.3\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Hct decreased from 25 to 22\n Imaging: CXR reviewed - no infiltrates, elevated left hemidiaphragm\n Assessment and Plan\n Gram positive septicemia likely from infected PICC.\n 1. Sepsis - likely line sepsis from PICC with 4/4 GPC. Would favor d/c\n ceftazidime, continue vanco. F/u on cultures. No need for pressors.\n Rule out endocarditis.\n 2. Hematuria - will ask urology to assess. U/a unremarkable for signs\n of infection, culture pending.\n 3. C2 quad - lives at . not vent dependent. Chronic pain.\n 4. Hx of pseudomonal UTI on .\n 5. Acute anemia - likely due to combination of hematuria and hydration\n 6. Decubitus ulcers\n 7. Acute renal failure - etiology possibly post-renal secondary to\n obstruction with clots seen on ultrasound vs. pre-renal secondary\n hypotension vs progression to ATN. Creat improving.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: Boots\n VAP: HOB elevation\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 32 minutes critical care time\n" }, { "category": "Physician ", "chartdate": "2117-02-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 408340, "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 See Dr note in chart for more details.\n 54 yr old male with C2 quadriplegia. Recent treatment for pseudomonal\n UTI and bacteremia. Admitted from rehab recently for delerium and\n fevers.\n Returned with hematuria, fever 103.2, drop in hct, 4/4 bottles positive\n for GPC.\n Subsequently BP decreased to 80 systolic\n 24 Hour Events:\n Central line inserted. Transfused 2 units PRBC.\n On CBI with frank bloody urethral discharge.\n Allergies:\n Heparin Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 11:30 PM\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 Musculoskeletal: chronic back pain\n Flowsheet Data as of 09:11 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: 57 (54 - 66) bpm\n BP: 94/63(70) {80/39(49) - 122/74(84)} mmHg\n RR: 9 (7 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 7 (3 - 7)mmHg\n Total In:\n 1,185 mL\n 963 mL\n PO:\n TF:\n IVF:\n 810 mL\n 588 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 2,500 mL\n 800 mL\n Urine:\n 2,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,315 mL\n 163 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, interm confused\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) 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: (Breath Sounds: Clear : ant but distant breath\n sounds)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, decub ulcer\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, , ED, Movement: Not assessed,\n Tone: Not assessed, quadriplegic\n Labs / Radiology\n 7.7 g/dL\n 217 K/uL\n 91 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 31 mg/dL\n 104 mEq/L\n 133 mEq/L\n 22.0 %\n 8.3 K/uL\n [image002.jpg]\n 04:50 AM\n WBC\n 8.3\n Hct\n 22.0\n Plt\n 217\n Cr\n 1.3\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Hct decreased from 25 to 22\n Imaging: CXR reviewed - no infiltrates, elevated left hemidiaphragm\n Assessment and Plan\n Gram positive septicemia likely from infected PICC.\n 1. Sepsis - likely line sepsis from PICC with 4/4 GPC. Would favor d/c\n ceftazidime, continue vanco. F/u on cultures. No need for pressors.\n Rule out endocarditis.\n 2. Hematuria - will ask urology to assess. U/a unremarkable for signs\n of infection, culture pending.\n 3. C2 quad - lives at . not vent dependent. Chronic pain.\n 4. Hx of pseudomonal UTI on .\n 5. Acute anemia - likely due to combination of hematuria and hydration\n 6. Decubitus ulcers\n 7. Acute renal failure - etiology possibly post-renal secondary to\n obstruction with clots seen on ultrasound vs. pre-renal secondary\n hypotension vs progression to ATN. Creat improving.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 PM\n Prophylaxis:\n DVT: Boots\n VAP: HOB elevation\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 32 minutes critical care time\n" }, { "category": "Physician ", "chartdate": "2117-02-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 408341, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:22 PM\n - transfused 2 units pRBCs, ordered for 1 more\n History obtained from Family / Medical records\n Allergies:\n History obtained from Family / Medical Agents\n Unknown;\n Last dose of Antibiotics:\n Ceftazidime - 11:00 PM\n Vancomycin - 11:30 PM\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 Musculoskeletal: leg pain and cramping\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: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 57 (54 - 66) bpm\n BP: 94/63(70) {80/39(49) - 122/74(84)} mmHg\n RR: 9 (7 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 67 Inch\n CVP: 7 (3 - 7)mmHg\n Total In:\n 1,185 mL\n 946 mL\n PO:\n TF:\n IVF:\n 810 mL\n 571 mL\n Blood products:\n 375 mL\n 375 mL\n Total out:\n 2,500 mL\n 800 mL\n Urine:\n 2,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,315 mL\n 146 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\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, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 217 K/uL\n 7.7 g/dL\n 91 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 31 mg/dL\n 104 mEq/L\n 133 mEq/L\n 22.0 %\n 8.3 K/uL\n [image002.jpg]\n 04:50 AM\n WBC\n 8.3\n Hct\n 22.0\n Plt\n 217\n Cr\n 1.3\n Glucose\n 91\n Other labs: PT / PTT / INR:14.7/29.3/1.3, Lactic Acid:1.0 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: Renal US - No hydronephrosis. No evidence of bladder mass,\n partially\n distended bladder with internal clots.\n Microbiology: - Blood Culture, Routine (Preliminary):\n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS AEROBIC BOTTLE .\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n Assessment and Plan\n 54 yo male with history of C2-C4 abscess with drainage complicated by\n quadriplegia was transferred to the for further management of\n severe sepsis.\n PLAN:\n 1. Severe Sepsis\n Patient was transferred from the floor with evidence of sepsis\n (temperature to 103.7 on admission and elevated WBC) and end organ\n dysfunction given his altered mental status. Most likely source of his\n sepsis is bacteremia given gram positive cocci in blood cultures.\n Etiology of his bacteremia is likely from PICC line that has been\n pulled, although an additional possibility includes sacral decubitus\n ulcer (although site appears clean and without purulent drainage).\n Additional sources include genitourinary source given hematuria. No\n additional evidence for pulmonary source given lungs relatively clear\n on exam, O2 sat appropriate on room air, and unremarkable CXR.\n - follow-up blood and urine cultures - on contact precautions \n speciation of gram + cocci\n - CXR- neg for acute cardiopulm process\n - fluid resuscitate with blood products and IVF boluses prn for goal\n MAP > 65\n - placed central line for possible initiation of pressors\n - start broad spectrum antibiotics with vancomycin to cover MRSA can\n d/c ceftazidime, f/u culture and sensitivities\n - re-culture\n - consider re-ordering MRI L spine if increased suspicion for\n osteomyelitis; will hold off on ordering now given acute renal failure\n - TTE this am to r/o cardiac seeding\n 2. Acute Renal Failure\n Etiology appears most likely either post-renal secondary to obstruction\n secondary to clots, pre-renal secondary to increased insensible losses\n / hypotension, or possibly progression to ATN given intermittent\n hypotension leading up to transfer.\n - send FE urea\n - renal US negative for hydro, did show clots within bladder\n - FeNa 2% suggestive of intrinsic process\n - spin urine today to evaluate for casts\n 3. Hematuria\n Unclear etiology for sudden development of hematuria given no clear\n history for Foley trauma. On CBI with persistently bloody urine, in\n interval when CBI bags being changed, urine noted to be frankly bloody\n by nursing\n - continue CBI\n - send urine cytology\n - consider urology consult if hematuria persists or if creatinine\n worsens\n - continue to transfuse for HCT>25\n 4. Anemia\n Patient with hematocrit decrease in the setting of persistent hematuria\n and IVF hydration. Differential includes blood loss secondary to\n hematuria.\n - check iron studies, vitamin B12, folate, and reticulocyte count\n - guaiac all stools\n - transfused 2 units pRBCs given concern for active bleeding, will\n continue to transfuse for HCT>25\n - check HCT q4h\n - maintain two peripheral IVs and active type and cross\n - d/c fondaparinux\n 5. Decubitus Ulcer\n Patient with Stage IV decubitus ulcer that appears clean and without\n evidence of infection.\n - wound care consult\n - continue zinc, vitamin C, vitamin B complex, and ascorbic acid\n 6. Chronic Pain and Muscle Spasms\n Patient with chronic pain and muscle spasms. Pain medications were held\n immediately prior to transfer given concern for altered mental status\n and lethargy. Blood pressure and mental status are now slightly\n improved.\n - continue patient's MS Contin\n - continue baclofen\n - will re-assess mental status in the AM and consider adding back prn\n morphine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:59 PM\n Multi Lumen - 09:22 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: possible call-out this pm\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408343, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting pain throughout the shift, unable to clearly identify\n source of pain, screaming out with discomfort with moving of linens and\n minimal activity, reporting pain at 10/10\n Action:\n Restarting home pain meds today, receiving PO MS Contin and Baclofen\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 408344, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting pain throughout the shift, unable to clearly identify\n source of pain, screaming out with discomfort with moving of linens and\n minimal activity, reporting pain at 10/10\n Action:\n Restarting home pain meds today, receiving PO MS Contin and Baclofen\n Response:\n Pt continues to report constant pain, tolerating well, pain especially\n with activity encouraging pt to breath\n Plan:\n Continue to monitor pain, ?increase pain meds if unable to control with\n home meds, ?chronic pain consult\n Impaired Skin Integrity\n Assessment:\n Pt with stage IV decub on coccyx, healed ulcers on heels bilat\n Action:\n Dsg changed on coccyx x2 per wound care recs, see wound care note for\n dsg recommendations, kerlex clean and intact on heels bilat, position\n change q2hr, pt with waffle boots on feet\n Response:\n Unknown\n Plan:\n Continue to monitor wounds, daily dsg changes per wound care\n Sepsis without organ dysfunction\n Assessment:\n Pt bp wnl throughout the day, see flowsheet for objective data\n Action:\n Blood cultures sent\n Response:\n Unknown\n Plan:\n Dailly blood cultures, continue to monitor pt for hypotension, treat\n with IVF or blood products as directed\n" } ]

[ { "category": "ECG", "chartdate": "2150-11-11 00:00:00.000", "description": "Report", "row_id": 300217, "text": "TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Normal sinus rhythm. P-R interval\nprolongation. Diffuse ST-T wave changes. Left anterior fascicular block.\nPoor R wave progression. Compared to the previous tracing of the rate\nhas slowed from 60 to 46. Intraventricular conduction delay and diffuse\nST segment changes persist with J point elevation in the right precordial leads\non the current tracing. Consider acute ischemia. T waves are slightly more\npeaked in lead V2 consistent with hyperkalemia.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2150-11-11 00:00:00.000", "description": "Report", "row_id": 300218, "text": "Sinus bradycardia. P-R interval prolongation. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing of no diagnostic\ninterval change. The diffuse non-specific ST-T changes may be slightly worse.\n\n" }, { "category": "ECG", "chartdate": "2150-11-11 00:00:00.000", "description": "Report", "row_id": 300216, "text": "TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Normal sinus rhythm. P-R interval\nprolongation. Marked left axis deviation. Poor R wave progression. Compared\nto tracing #1 there is less peaking of the T wave in the right precordial leads\nconsistent with improvement in hyperkalemia.\nTRACING #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2127-12-18 00:00:00.000", "description": "Report", "row_id": 62343, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congenital heart disease. Coronary artery disease. Myocardial infarction.\nBP (mm Hg): 115/44\nStatus: Inpatient\nDate/Time: at 10:06\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLarge pleural effusion is noted.\nLEFT ATRIUM: The left atrium is moderately dilated. The left atrium is\nelongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - dyskinetic; basal inferoseptal -\nakinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior\n- akinetic; the remaining left ventricular segments are hypokinetic.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: There are three aortic valve leaflets. The aortic valve leaflets\nare moderately thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets are thickened.\nPhysiologic (normal) pulmonic regurgitation is seen. The main pulmonary artery\nis dilated.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The left atrium is elongated. The right\natrium is moderately dilated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed. Resting regional wall motion abnormalities include\ndyskinesis of the basal and mid interventricular septum and akinesis of the\nbasal and mid posterior wall. The remaining left ventricular segments are\nhypokinetic. Right ventricular chamber size and free wall motion are normal.\nThere are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. The mitral valve leaflets are mildly thickened. Moderate\n(2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. The pulmonic valve leaflets are\nthickened. The main pulmonary artery is dilated. There is a\ntrivial/physiologic pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2127-12-18 00:00:00.000", "description": "Report", "row_id": 120473, "text": "Probably atrial fibrillation with variable ventricular response\nLead(s) unsuitable for analysis: V1\nIndeterminate frontal QRS axis\nQT long for rate\n Anterolateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing, probably no significant change\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2127-12-16 00:00:00.000", "description": "Report", "row_id": 120474, "text": "Atrial fibrillation with a slow ventricular response. Occasional ventricular\nectopy. Q waves in leads II, III and aVF consistent with a prior inferior\nmyocardial infarction. Compared to the previous tracing of ventricular\nectopy is now present, the precordial lead placement has changed and the rhythm\nis now irregular consistent with atrial fibrillation. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2127-12-16 00:00:00.000", "description": "Report", "row_id": 120514, "text": "Probable underlying atrial fibrillation with a regular junctional escape rhythm\nat 45 beats per minute. Intraventricular conduction delay. Low limb lead\nvoltage. Q waves in leads II, III, aVF consistent with a prior inferior\nmyocardial infarction. Non-specific scooped ST segments in leads V5-V6\nconsistent with digitalis effect. Compared to the previous tracing of \nthe ventricular ectopy has resolved, the rate has slowed, and the rhythm has\nbecome regular. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2127-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750802, "text": " 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: to check for free air under diaphram, PLEASE do full upright\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT s/p ? feeding tube placement\n REASON FOR THIS EXAMINATION:\n to check for free air under diaphram, PLEASE do full upright/erect standing\n port chest film.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Feeding tube placement, ? free air under diaphragm.\n\n PORTABLE CHEST AT 3:12 A.M.: An erect portable chest x-ray was obtained. No\n pneumoperitoneum is identified.\n\n" }, { "category": "Radiology", "chartdate": "2127-12-19 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 750692, "text": " 12:04 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ? aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: R/O aspiration in patient with a history of recurrent aspiration\n pneumonia.\n\n VIDEO SWALLOW: This study was performed in conjunction with a speech\n therapist. Various consistencies of barium were administered orally. In the\n oral phase there is incoordinate muscular movement and bolus formation. In\n the pharyngeal phase there is delayed epiglottic deflection and normal\n laryngeal elevation with significant residue in the valleculae. There is\n moderate laryngeal penetration and moderate aspiration.\n\n IMPRESSION:\n\n Moderate laryngeal penetration and moderate aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2127-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750785, "text": " 4:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of feeding tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT\n REASON FOR THIS EXAMINATION:\n placement of feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Feeding tube placement.\n\n There are increasing pleural effusions. Feeding tube terminates below the GE\n junction since . Pulmonary vascularity is normal.\n\n IMPRESSION: Feeding tube insertion since .\n\n Otherwise, no significant change in the chest.\n\n" }, { "category": "Radiology", "chartdate": "2127-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750797, "text": " 10:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: FEEDING TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT\n REASON FOR THIS EXAMINATION:\n FEEDING TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube placement.\n\n PORTABLE CHEST: The appearance of the chest has not changed significantly\n since prior chest x-ray of . The distal end of the feeding tube is seen\n to be along the greater curvature of the stomach terminating in the pyloro-\n duodenal region. The large bilateral pleural effusions are again noted.\n\n IMPRESSION: The feeding tube appears to terminate in the pyloroduodenal\n region. The appearance of the chest is otherwise unchanged since 5pm on\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2127-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750539, "text": " 2:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desat to 88% on NRB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT\n REASON FOR THIS EXAMINATION:\n desat to 88% on NRB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased O2 saturation.\n\n COMPARISON: .\n\n There is cardiomegaly, which is not changed compared to the prior study.\n There has been interval increase in the haziness in the perihilar region and\n bibasilar consolidations most likely representing effusions. There is no\n significant upper zone redistribution of the pulmonary vasculature. Overall,\n this likely suggests cardiac decompensation and CHF. Osseous structures are\n unchanged.\n\n IMPRESSION:\n\n 1. Increase in the perihilar haze associated with bilateral small pleural\n effusions and cardiomegaly. This likely represents cardiac decompensation and\n pulmonary edema. This appearance has worsened compared to the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2127-12-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 750490, "text": " 10:39 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate or effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with failure to thrive.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate or effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Age with failure to thrive. Check for infiltrate or effusion.\n\n FINDINGS: Standard PA and left lateral views. Comparison study dated\n . There is evidence of slight LV enlargement associated with bilateral\n plerual effusions of moderate size, larger than on the prior study. In\n addition, there is now evidence of collapse and consolidation of both the left\n lower lobe and right lower lobe. There may be slight upper zone\n redistribution.\n\n IMPRESSION:\n\n The appearances suggest left heart failure with bilateral lower lobe collapse\n and consolidation. These findings are worse than on the prior study of\n .\n\n" }, { "category": "Radiology", "chartdate": "2127-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750578, "text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: yo M w/ acute onset hypoxia, new b/l lower lobe densities\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with FTT\n REASON FOR THIS EXAMINATION:\n yo M w/ acute onset hypoxia, new b/l lower lobe densities on CXR yest PM->\n presumed aspiration. wish to follow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New onset hypoxia and presumed aspiration.\n\n AP UPRIGHT CHEST: The right lung is hyperinflated. Although the left lung may\n be hyperinflated as well, a large pleural effusion obscures the left\n hemidiaphragm. The heart is slightly enlarged. The mediastinal and hilar\n contours are within normal limits. Gradient opacification of both lung fields,\n with relative aeration of the apices suggests a combination of layering\n effusion posteriorly and perihilar vascular indistinctness. The left lower\n lobe consolidation cannot be excluded. Skeletal structures are unremarkable.\n\n IMPRESSION: Compared to the exam, there has been interval increase in the\n bilateral pleural effusions. This is most likely secondary to CHF superimposed\n on emphysema. However, a CT scan may be useful to delineate the extent of\n effusion vs. consolidation.\n\n" }, { "category": "Nursing/other", "chartdate": "2127-12-17 00:00:00.000", "description": "Report", "row_id": 1498142, "text": "Pmicu Nursing Admission Note\n year old male admitted from 2 with aspiration Pneumonia.\n\nPast medical history: HTN; Afib; microscopic hematuria.\n\nAllergies: codeine\n\nPt was admitted to on with failure to thrive. He was being hydrated with consults to podiatry and wound care. He was walking in the today with PT. ~1500 he started to C/O SOB with O2 sats 83 on room air. He was placed on 4l NC but sats only improved to 86%, FiO2 was increased to 100% Non rebreather. He was deep suctioned by resp for minimal amount of secretions, ? aspiration pneumonia. He continued to have low sats so was place on BiPap with some success. PaO2 only increased to 55. He was transfered to Micu for further management.\n\nReview of systems: Pt arrived on 100% NRB O2 sats 99%. RR 20's. Pt attempted NT suctioning with great difficulty, with minimal success. Breath sound with coarse crackles on the left with decrease breath sounds on the right.\n\nCardiac: B/P 133/70, HR 90's-100, Afib with frequent PVC's.\n\nGI: Abd soft and non tender, (+) bowel sounds. His belly is concave. He has bilateral inguinal hernias right > left.\n\nGU: Foley in place draining light yellow urine from the lasix 40mg. U/O from the lasix was 1400cc.\n\nNeuro: Pt is awake, alert, and cooperative. MAE.\n\nSkin: Pt is very cachectic. The skin on his body is extremely dry and the skin is flaking off, some of the flakes are causing bleeding. His feet are so dry they are white with ? fungus. He has skin tears and bruising on his arms. His coccyx is reddened with no breakdown.\n\nSocial: He lives in at House by himself. He is separated from his wife who lives in . with one oftheir 2 daughters. His son lives in who sees him twice/mo. His daughters: ; ().\n" }, { "category": "Nursing/other", "chartdate": "2127-12-18 00:00:00.000", "description": "Report", "row_id": 1498143, "text": "NPN\n\nCV: SNP 90s-low 100s, HR 40s-50s occationally into the 30s and 60-70s, afib, freq PVCs. HO aware of decreased HR but said that he would tolerate this as long as his BP did.\n\nPulm: BS coares, deminished at the bases, his cough is fairly weak but he is able to bring up some lt yellow to tan, thick secretions - he has been using the yankaur with some effect. He conts on the bipap with his SATs in the high 90s; no abgs were drawn.\n\nGI: NPO at present, feeding needs to be addressed right away. He states that he has seen a weight loss of 10 lbs over the last year, says that he does eat but only about half of his meals and his appitite has been decreasing.\n\nGU: He had an excellent responce to lasix, too much so and was given 500cc back. K was 4.3, mg repleted.\n\nNeuro: A&Ox3, pleasant, cooperative\n\nSkin: Conts to flake, pediatry was in and spent time scubbing and wrapping his feet, they recommend /TID washing of feet with spunge or surgical scrub using mold soap, put gauze between toes to prevent maceration.\n" } ]

[ { "category": "Echo", "chartdate": "2135-10-27 00:00:00.000", "description": "Report", "row_id": 71423, "text": "PATIENT/TEST INFORMATION:\nIndication: LV Fxn, CHF, Afib, F/U limited R/O SBE\nHeight: (in) 72\nWeight (lb): 200\nBSA (m2): 2.13 m2\nBP (mm Hg): 145/82\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:45\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV function depressed.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. There is mild-to-moderate global left ventricular\nhypokinesis. Right ventricular systolic function appears depressed. The\ntricuspid valve leaflets are mildly thickened. There is no pericardial\neffusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , left ventricular contractile function appears unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889100, "text": " 1:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pulmonary edema vs. PNA\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers, bibasilar crackles, increasing O2 requirements, tachypnea, aspiration\n risk\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary edema vs. PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fever, bibasilar crackles, and worsening oxygen requirement.\n\n The heart is enlarged but stable. There is vascular engorgement and perihilar\n haziness as well as an area of slightly asymmetric more confluent opacity in\n the right upper lobe. An underlying interstitial pattern is present as well.\n Overall, the degree of opacification in both lungs has improved in the\n interval.\n\n IMPRESSION: Findings likely due to improving asymmetrical pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2135-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888817, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, volume status\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers and new oxygen requirement.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, volume status\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:30 A.M., \n\n HISTORY: MRSA bacteremia and epidural abscess. New oxygen requirement.\n\n IMPRESSION: AP chest compared to :\n\n Study is rotated to the right. Lungs are grossly clear. Mild cardiomegaly\n unchanged. The lateral aspect of the right hemithorax is excluded from the\n examination. There is no appreciable pleural effusion on either side nor any\n evidence of pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2135-11-18 00:00:00.000", "description": "Report", "row_id": 175131, "text": "Atrial flutter/fibrillation\nConsider old septal infarct\n Inferior/lateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2135-11-11 00:00:00.000", "description": "Report", "row_id": 175132, "text": "Atrial flutter\nNonspecific ST-T wave changes\nSince previous tracing of , less suggestive of prior anteroseptal\nmyocardial infarction - may be in part positional\n\n" }, { "category": "ECG", "chartdate": "2135-11-09 00:00:00.000", "description": "Report", "row_id": 175133, "text": "Atrial flutter\nProbable prior anteroseptal myocardial infarction\nNonspecific ST-T wave abnormalities\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2135-11-07 00:00:00.000", "description": "Report", "row_id": 175134, "text": "Atrial flutter with rapid ventricular response. The atrial rate is slow. Prior\nanteroseptal myocardial infarction. Non-specific ST-T wave abnormalities.\nCompared to the previous tracing of the atrial rate has slowed.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2135-10-31 00:00:00.000", "description": "Report", "row_id": 175356, "text": "Atrial flutter\nProbable prior anteroseptal myocardial infarction\nNonspecific ST-T wave changes\nSince previous tracing of , more suggestive of prior anteroseptal\nmyocardial infarction\n\n" }, { "category": "ECG", "chartdate": "2135-10-26 00:00:00.000", "description": "Report", "row_id": 175357, "text": "Atrial flutter\nPossible prior anteroseptal myocardial infarction although is nondiagnostic\nNonspecific ST-T wave abnormalities\nSince previous tracing of , poor R wave progression improved and ST-T\nwave changes less prominent\n\n" }, { "category": "ECG", "chartdate": "2135-10-25 00:00:00.000", "description": "Report", "row_id": 175358, "text": "Atrial flutter with rapid ventricular response\nProbable septal myocardial infarction\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested - clinical correlation is\nsuggested\nSince previous tracing of , Ventricular rate faster and further ST-T\nwave changes present\n\n" }, { "category": "Nursing/other", "chartdate": "2135-11-09 00:00:00.000", "description": "Report", "row_id": 1375241, "text": "NPN 7P-7A:\n\nNEURO: PT IS A/OX1. HE FOLLOWS COMMANDS. HE IS ABLE TO MOVE ALL EXT.\n\nCV: A FIB. HE HAD A 7 BEAT RUN OF VT. HIS B/P REMAINED 150'S. HE DENIED CHEST PAIN. HE GOT A EXTRA DOSE OF LOPRESSOR 25MG . HIS HR REMAINE IN THE >110.\n\nRESP: LS COURSE BILAT UPPER LOBES, AND CRACKLES LOWER LOBES. O2 SAT 100% ON 3L NC. HIS RR WENT UP TO 30. ABG WAS 7.46/38/111/28/2. NO CHANGES MADE. HE IS COUGHING UP A LARGE AMOUNT OF CLEAR SPUTUM.\n\nGI/GU: NEPRO AT 55CC/HR. NO RESIDUAL NOTED. MED GIVEN VIA GT. + BS. NO BM. FOLEY CATH W/ >50CC/HR.\n\nPOC: MONITOR FOR ASP. O2 SUPPORT. QUESTION A CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2135-11-08 00:00:00.000", "description": "Report", "row_id": 1375238, "text": "NPN 7P-7A:\n\n\nNEURO: PT INTUBATED AND SEDATED ON FENTANYL 10MCH/HR AND MIDAZOLAM 0.5MG/HR. THE FENTANYL WAS WEANED FROM 15MCG TO 10MCG SECONDARY TO QUESTION OF EXTUBATION THIS AM. HE IS ABLE TO FOLLOW COMMANDS. HE AT TIMES ATTEMPTS TO MOUTH WORDS. HE DOSE NODES HIS HEAD QUESTIONS ASKED. HE DENIED PAIN.\n\nCV: A-FIB HR 80-90'S W/ PVC NOTED. CVP 14. LEVOPHED IS OFF NOW. B/P 127/66. HIS LOPRESSOR IS NOW D/C.\n\nRESP: LS DIMINSHED BILAT UPPER LOBES, AND RONCH BILAT LOWER LOBES. SCANT TO NO SPUTUM NOTED WHEN SX. VENT SETTINGS: 40%X550X20 W/ 5PEEP.\n\nGI/GU: TUBE FEEDINGS IS NEPRO FULL STRENGTH NOW AT 40ML AT THIS TIME. HIS GOAL RATE IS 55ML HOUR. HIS H2O FLUSH WAS HELD SECONDARY TO RESIDUAL OF 100. + BS NO BM. FOLEY CATH W/ GOOD OUT PUT.\n\nI/D: A FIBRIAL. HE IS ON IMIPENEM. AND HE IS ON TOBRAMYCAN INHALANTS SECONDARY TO A QUESTION OF FUNGAS IN HIS LUNGS ON A BRONCH. HIS CULTURES ARE PENDING.\n\nSKIN: ON HIS RIGHT GRATE TOE IS AMPUTATED AND HE HAS HE HAS SUTURES INTACT. HIS BUTTOCKS ARE PINK. HIS SPINE IS A STAGE ONE.\n\nPOC: QUESTION EXTUBATION TODAY. ABX.\n" }, { "category": "Nursing/other", "chartdate": "2135-11-08 00:00:00.000", "description": "Report", "row_id": 1375239, "text": "Resp Care\nPt. remains intubated t/o night. Occ. overbreathing 1-2 breaths. This morning rsbi was acceptable, placed on PSV 10/5, abgs to be sent.\nBs: coarse bilat. sxn'd for mod. thick yellow x2.\nTobramycin 300mg given last evening at 0900. Albuterol q4.\nPlan: SBT this morning, abg, extubate if tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2135-11-08 00:00:00.000", "description": "Report", "row_id": 1375240, "text": "NPN 0700-1900\nNeuro: Pt. but disorinted. Pt. off sedation and able to move all ext. Speech slightly garbeled due to resp. congestion.\n\nResp: Pt. extubated at 1000 AM. Lots of secrestions but Pt. able to cough them up. Orally suctioned very frequently throughout the day. Secretions thick white. BLA from bronch + for Acinetobactor and other cx. pending. Pt. cont. on inh. Tobramycin. LS coares occ. exp. wheez. Pt. recieved albuterol neb and cough med. RR 20-30 non labored. ABG at 1630 see carevue fro results.\n\nCV: ABP 141-151/66-76 HR 110-112 thoughout the shift with occ. PVC's noted. Pt. restarted on Metoprolol and an extra dose given at 1600 with no signigicant decrease in HR or BP. Pt. recieved 40 mg IV Lasix for CHF per CT of chest and AM Cxr and diuresed well. K 3.8 this AM and repleated with 40 Meq of PO KCL. PM lytes at 1630, see carevue for details.\n\nGI: Pt. cont. on Nepro tube feedings at 55cc/hr with no residuals all day. Pt. tolerating water flushes well. Pt. moving bowels x2 today both OB neg. Abd. soft, nontender, BS+.\n\nGU: Foley cath in place and draining adequate amounts of clear yellow urine. BUN 44 creat 1.9 today. Fluid balance -540cc for 24 hr after lasix. +1145cc for LOS. No edema noted .\n\nID: Pt. afebrale. Cont. on IV Imepenem and inh. Tobramycin. Vanco dosed per levels. No dose today will speek with intern.\n\nSkin: Pt. has order for PT measure for new back/ thorasic brace, Not in this shift.Possibley in AM.\n\nSocial; Pt. is a full code. Pt's family wife daughter and son in. updated by MD on Pt.'s condition and progress. Will cont.to update and support Pt.'s family.\n\n" }, { "category": "Nursing/other", "chartdate": "2135-11-01 00:00:00.000", "description": "Report", "row_id": 1375235, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: UTA orientation. Responds to stimuli/voice. Follows commands intermittently. Remains on low dose prop while intubated. MAE\nCV: HR-Afib tachy to 120's mult times iv lopressor given over nocX2 with short acting affect. PO lopressor increased for rate controll T-max 101.3 Pan cx. Tylenol prn. Pt with 4pt crit drop this am MICU resident MD is aware no intervention at this time\nResp: Resp acidosis resolving. No vent changes made over noc. Remains on CMV .50% Fi02 TV 600X16. Sats >95% Lungs clear throughout. Secretions thk but clear sputum cx sent\nGI/GU: TF started over noc pt tolerating well. 2 BM's over noc both guiac neg. Abd soft NT. Foley patent drng yellow urine.\nID: MRSA precautions. Cont on levo and flagyl\nEndo: no RISS\nPlan: Cont to monitor hemodynamics. Begin to wean from vent. Cont to monitor pt's rising BUn/Creat. Cont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2135-11-02 00:00:00.000", "description": "Report", "row_id": 1375236, "text": "data: afebrile, hr 100-118af w/o ectopies. lopressor 100mg via g-tube\nq8hr and prn lopressor 5mg x2 for rate control. cvp 7-5. urine output\n~100cc/hr. pt oriented x2. confused to place @ times. follows command\ntolerating t. fdg nepro@50cc(goal rate). sodium remains high 148-rec'ing free h20 250cc q4hr. +bs no bm.\nresp-cs clear decease in bases. coughing not raising. o2sat 99% on np4lrs. rr 24-30 non-labored.\n" }, { "category": "Nursing/other", "chartdate": "2135-11-07 00:00:00.000", "description": "Report", "row_id": 1375237, "text": "NPN 0700-1900\nNeuro: Pt. intubated and sedated with Fentanyl 15mcg/hr and Versed 0.5mg/hr. Pt. opens eyes to voice and stimuli does not follw commands. Pupils 2mm round equal and reactive.\n\nResp: Pt. intubated fro worstening resp. status ? aspiration pneumonia vs. septic emboli. CT of chest done today. Plan to perform Branchoschopy today. Pt. vented on A/C 550x20 with PEEP of 5 and FiO2 40%. Last ABG at 1600 pH 7.46 PaCO2 38 PaO2 135. Pt. requiered frequent suctioning this AM for small amounts of thick white sputum. Order for sputum for culture and gram stain, resp. therapist will collect it. LS coarse bil. O2 sat 96-100%.\n\nCV: ABP 182-150/54-80. HR 74-84 A-fib with rare PVC's. K 3.4, Mg 1.7 this AM repleated this PM. Pt. on Levophed at 0.02 mcg/kg/hr to keep MAP.65. Will attempt to wean if possible. Petiechiae noted to both palms and poserior arms also few on feet. None noted to abd. or back.\n\nGI: GT in place and started on Nepro currently at 30cc/hr to be increased q 4 hr by 10 cc for a goal of 55cc/hr. Last residual 25cc at 1600. Pt. recieving H2O flushes 300cc q 4 hr as well. Pt. has large loose BM this AM OB negative.\n\nGU: Foley cath in place and draining adequate amount of clear yellow urine. BUN 49 creat 2.0 improving.\n\nSkin: Pt. s/ toe amputation. Site open to air with old blood to area no redness or swelling noted. Pt. also has small 1mc round red blister to posterior heel on L leg. Coccyx red unopened. Barrier cream applied and Pt. has been repositioned frequently.\n\nID: Afebrale. Pt. seen by ID team and will change abx. to Imepenum and Tobramycin and will D/C Flagyl and Levoquin. Will follow creatnine levels and dose med appropriatly.\n\nSocial: Pt.'s wife and daughter at bedside for most of the day very supportive, asking many questions. Family updated by Dr. . Pt. is a full code.\n" }, { "category": "Radiology", "chartdate": "2135-10-27 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 888694, "text": " 12:07 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal bleed\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o epidural abscess and MRSA bacteremia, on coumadin at\n rehab, PEG tube, admitted with ARF, anemia, Hct failed to increased\n appropriately after transfusion\n REASON FOR THIS EXAMINATION:\n evaluate for retroperitoneal bleed\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINOPELVIC CT\n\n HISTORY: 73-year-old male with history of epidural abscess and bacteremia, on\n Coumadin, anemic. Rule out retroperitoneal bleed.\n\n TECHNIQUE: Multidetector CT through the abdomen and pelvis without contrast.\n\n Comparison is made with prior study dated .\n\n ABDOMEN CT: In the limited images obtained throughout the bases of the lungs,\n there is mild a pleural effusion. Lung window images are limited secondary to\n patient respiration; some peripheral non-well-defined opacities are seen in\n the right lung base, likely atelectasis. Marked interlobular septa. There is\n moderate cardiomegaly. Multiple calcifications are seen in the coronary\n arteries.\n\n The liver, spleen, pancreas, gallbladder, adrenals, and kidneys are\n unremarkable in this non-contrast study. There is no free air or free fluid\n within the abdomen. There is a PEG tube in place. Otherwise, the small bowel\n loops are unremarkable.\n\n The aorta is heavily calcified, measures up to 33 x 31 mm.\n\n PELVIC CT: Multiple diverticula are seen in the sigmoid without stranding of\n the adjacent pericolonic fat. There is no free fluid. There is a Foley\n catheter in the lumen of the bladder. There is no lymphadenopathy.\n\n There are no signs of retroperitoneal bleed.\n\n BONE WINDOWS: Changes of extensive laminectomy extending up the thoracic\n vertebral bodies to L4 vertebral body. There are no adjacent collections, gas\n bubbles, or signs of bleeding in the soft tissues of the back.\n\n IMPRESSION:\n 1. There are no signs of retroperitoneal bleed.\n 2. Diverticulosis without diverticulitis.\n 3. Left pleural effusion with bibasal small subsegmental atelectasis.\n (Over)\n\n 12:07 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal bleed\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Extensive post-operative changes in the posterior soft tissues of the back\n post extensive laminectomy as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890352, "text": " 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: now extubated, eval for infiltrates, ?pulmonary nodules\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess, aspiration\n with persistent low grade fevers now growing Acenitobacter in sputum,\n decreased O2 Sats 85%RA\n REASON FOR THIS EXAMINATION:\n now extubated, eval for infiltrates, ?pulmonary nodules\n ______________________________________________________________________________\n FINAL REPORT\n STUDIES: PORTABLE AP CHEST.\n\n INDICATION: MRSA bacteremia, aspiration, fevers, low sats.\n\n COMPARISON: .\n\n There is worsening of moderate congestive heart failure. There is a new\n opacity in the right lower lobe, likely represents pneumonia, or atelectasis.\n Left lower lobe atelectasis is unchanged. ET tube has been removed. Median\n sternotomy wires, surgical clips identified. No pneumothorax. The heart is\n enlarged, the mediastinal caliber is also enlarged secondary to worsening\n failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889016, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers and new oxygen requirement.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of fever and increased oxygen requirement in patient with epidural\n abscess.\n\n Status post CABG. There is cardiomegaly and tortuosity of the thoracic aorta.\n There are bilateral predominantly perihilar ill-defined air-space opacities,\n new since the prior study of , which could represent pulmonary\n edema although evolving pneumonia cannot be ruled out in the presence ofthe\n provided clinical information. Correlate clinically and with followup after\n therapy to reevaluate.\n\n" }, { "category": "Radiology", "chartdate": "2135-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890206, "text": " 5:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infilrates, ?septic emboli on prior CXR\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess, aspiration\n with persistent low grade fevers now growing Acenitobacter in sputum,\n decreased O2 Sats 85%RA\n REASON FOR THIS EXAMINATION:\n eval for infilrates, ?septic emboli on prior CXR\n ______________________________________________________________________________\n FINAL REPORT\n , 6:30 A.M., AP CHEST\n\n HISTORY: MRSA bacteremia and low-grade fever.\n\n IMPRESSION: AP chest compared to :\n\n Mild pulmonary edema has nearly resolved. Mild cardiomegaly stable. No\n appreciable pleural effusion. Mild residual opacification in the left lower\n lobe more likely atelectasis than pneumonia.\n\n ET tube in standard placement. Tip of a left subclavian line is at the\n junction of the brachiocephalic veins.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-17 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 891490, "text": " 3:43 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST; MR CONTRAST GADOLIN\n Reason: follow progression vs. improvement of epidural abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with epidural abscess\n REASON FOR THIS EXAMINATION:\n follow progression vs. improvement of epidural abscess\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL SPINE WITH AND WITHOUT CONTRAST\n\n CLINICAL HISTORY: Followup epidural abscess.\n\n TECHNIQUE: Sagittal, pre- and post-contrast T1-weighted images, T2-weighted\n and STIR images and axial gradient echo images were obtained. Some of the\n images are limited by patient motion.\n\n FINDINGS:\n\n No cervical epidural collection is seen. As seen on the study from ,\n there is spondylosis with disc space osteophyte seen at each of the levels\n between C2 and C7. At C3-4, osteophytes flatten the spinal cord somewhat and\n there is foraminal stenosis, worse on the right than the left. There is\n flattening of the spinal cord at C4-5 as well with severe bilateral foraminal\n stenosis. There is some foraminal stenosis at C5-C6. The C6-7 and C7-T1\n foramina are poorly seen on the axial images due to artifact, but the canal is\n well maintained.\n\n IMPRESSION:\n 1. No cervical epidural abscess or collection is seen.\n 2. There are degenerative disc disease changes and there is stenosis of the\n spinal canal from osteophytes at C3-4 and C4-C5 with mild-to-moderate\n flattening of the spinal cord, but no definite abnormal signal intensity in\n it.\n\n MRI OF THE THORACIC SPINE WITH AND WITHOUT CONTRAST:\n\n TECHNIQUE: Sagittal and axial T1-weighted, T2-weighted and post-contrast\n T1-weighted images were obtained. Sagittal STIR images were also obtained.\n\n FINDINGS:\n\n As seen previously, there have been laminectomies at the T4-L3 levels.\n Currently, there is enhancing granulation tissues/scar in the surgical defect\n and the superficial superiorly directed fluid collection seen on has\n essentially resolved. No epidural abscess is seen.\n\n There are multilevel endplate degenerative changes without marrow\n abnormalities that suggest discitis/osteomyelitis. Small disc space\n (Over)\n\n 3:43 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST; MR CONTRAST GADOLIN\n Reason: follow progression vs. improvement of epidural abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n osteophytes are noted and there is a small central disc herniation at the\n T11-12 level. It indents the thecal sac but does not appear to affect the\n distal spinal cord.\n\n IMPRESSION:\n 1. There is no recurrence of the epidural abscess.\n 2. The superficial upper thoracic fluid collection has resolved with further\n improvement compared to .\n\n MRI OF THE LUMBAR SPINE\n\n CLINICAL HISTORY: Epidural abscess.\n\n TECHNIQUE: Sagittal and axial T1-weighted, T2-weighted and post-contrast\n T1-weighted images were obtained.\n\n FINDINGS:\n\n The extensive laminectomies extend down to the L3 level and the superior\n portions of the L4 posterior elements have also been resected. There is no\n recurrence of the extensive epidural abscess seen on the study. There\n are degenerative disc disease changes as seen originally with disc bulges at\n each of the levels between L1 and S1 and mild spondylolisthesis at L4-5 and\n L5-S1. There is some stenosis of the L4-5 foramina, particularly the left.\n The nerve roots of the cauda equina are grossly normal. There is a focus of\n T1- and T2-hypointensity adjacent to the residual spinous process of L4, most\n consistent with metallic artifact. No superficial fluid collection is seen.\n\n IMPRESSION: There is no evidence of a residual or recurrent abscess. There\n is a left foraminal disc herniation at L4-5, present on , which might\n affect the left L4 nerve root.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891126, "text": " 10:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: F/U Pneumonia\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess,\n aspiration, growing Acenitobacter in sputum.\n REASON FOR THIS EXAMINATION:\n F/U Pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MRSA Bacteremia and epidural abscess.\n\n IMPRESSION: AP chest compared to :\n\n Moderate cardiomegaly unchanged. Lungs grossly clear. No significant pleural\n effusion or indication of pneumothorax. Central lines have been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889220, "text": " 4:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for pna, chf\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers, bibasilar crackles, increasing O2 requirements, tachypnea, aspiration\n risk\n REASON FOR THIS EXAMINATION:\n eval for pna, chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n INDICATION: 73-year-old man with history of MRSA bacteremia, increasing O2\n requirements, eval for pneumonia, CHF.\n\n COMPARISON: at 1:30 a.m.\n\n FINDINGS: An endotracheal tube is now present in good position. Otherwise,\n the chest x-ray is unchanged with evidence for vascular engorgement indicating\n element of pulmonary edema.\n\n IMPRESSION: Unchanged pulmonary edema with new ET tube in good location.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 890671, "text": " 2:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check picc tip position. #4f, sl, v-cath for abx. ple\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess,\n aspiration, growing Acenitobacter in sputum.\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #4f, sl, v-cath for abx. please page beeper\n # with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST OF \n\n COMPARISON: Previous study of .\n\n INDICATION: PICC line placement.\n\n A right PICC line is malpositioned, with the distal tip directed cephalad\n within the right internal jugular vein. A left subclavian vascular catheter\n remains in satisfactory position. Neck and mediastinal contours are stable.\n There has been interval improved aeration in the right lower lobe with near\n complete resolution of previously noted opacity.\n\n IMPRESSION: Malpositioned right PICC line. This finding was discussed by\n phone with the IV nurse caring for the patient.\n\n" }, { "category": "Radiology", "chartdate": "2135-11-11 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 890684, "text": " 3:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please reposition PICC\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O PORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o afib, MRSA infection, whose double lumen PICC placed\n today is malpositioned.\n REASON FOR THIS EXAMINATION:\n Please reposition PICC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with MRSA infection requiring PICC for long-term IV\n antibiotics. PICC placed at the bedside was malpositioned with the tip in the\n right internal jugular vein.\n\n PROCEDURE AND FINDINGS: The procedure was performed by doctors and\n , the attending physician who was present and supervising. The\n patient's right arm and PICC were prepped and draped in standard sterile\n fashion. A fluoroscopic examination demonstrated the PICC tip to be in the\n right internal jugular vein. Under fluoroscopic guidance, the catheter was\n withdrawn and re-advanced into the SVC. The wire was removed. The line was\n flushed and heplocked and secured with a StatLock. Final chest image\n demonstrated appropriate positioning of the line tip in the distal SVC. The\n patient tolerated the procedure well and there are no immediate post-procedure\n complications.\n\n IMPRESSION: Successful repositioning of right-sided PICC with the tip now in\n the distal SVC. The line is ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890054, "text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF exacerbation, vs consolidation, pleural effusions\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess, aspiration\n with persistent low grade fevers now growing Acenitobacter in sputum,\n decreased O2 Sats 85%RA\n REASON FOR THIS EXAMINATION:\n CHF exacerbation, vs consolidation, pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:25 A.M. \n\n HISTORY: Hypoxia.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes have increased but mild generalized interstitial abnormality has\n developed in the left lung with more consolidative features on the right, most\n likely pulmonary edema. Heart is slightly larger, at upper limits of size.\n Left subclavian line tip projects over the brachiocephalic vein. No\n pneumothorax. Tiny right pleural effusion may be present.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889237, "text": " 6:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p left subclavian placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers, bibasilar crackles, increasing O2 requirements, tachypnea, aspiration\n risk\n REASON FOR THIS EXAMINATION:\n s/p left subclavian placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old with MRSA bacteremia and epidural abscess with fever\n and increasing oxygen requirement. Evaluate left subclavian catheter\n placement.\n\n Supine frontal view of the chest. Comparison is made to study performed two\n hours earlier.\n\n The right hemithorax is only partially visualized with exclusion of the\n lateral aspect. There has been interval placement of a left subclavian\n central venous catheter with its tip in the proximal SVC. No pneumothorax is\n identified. An endotracheal tube remains in place. There has been no change\n in the appearance of the left lung field.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-10-25 00:00:00.000", "description": "RENAL U.S.", "row_id": 888470, "text": " 10:03 PM\n RENAL U.S. Clip # \n Reason: ACUTE RENAL FAILURE\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with arf\n REASON FOR THIS EXAMINATION:\n r/o hydronephrosis\n ______________________________________________________________________________\n WET READ: MJGe TUE 10:25 PM\n no hydronephrosis. normal appearing kidneys.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure.\n\n RENAL ULTRASOUND: The right kidney measures approximately 10.9 cm. The left\n kidney measures 11.7 cm. The lower pole of the right kidney is not\n visualized, and review of prior CT scan shows there has been resection of the\n lower pole. Neither kidney contains stones or demonstrates hydronephrosis.\n Limited views of the liver and bladder are unremarkable.\n\n IMPRESSION: No evidence of hydronephrosis or stones. Status post resection\n of lower pole of right kidney.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889273, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval cxr, evaluate ETT placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess now with\n fevers, bibasilar crackles, increasing O2 requirements, tachypnea,\n aspiration risk/ S/p intubation on \n REASON FOR THIS EXAMINATION:\n interval cxr, evaluate ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:10 A.M. ON .\n\n HISTORY: MRSA bacteremia and epidural abscess. Increasing hypoxia.\n\n IMPRESSION: AP chest compared to and 14:\n\n Mild pulmonary edema has improved since , although mild-to-moderate\n cardiomegaly has not and there is still some mediastinal venous engorgement.\n No appreciable pleural effusion is seen nor is there evidence of pneumothorax.\n No focal pulmonary abnormality is present to suggest pneumonia. ET tube and\n left subclavian line are in standard placements.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889940, "text": " 6:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, assess volume status\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess, aspiration with\n persistent low grade fevers now growing Acenitobacter in sputum.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, assess volume status\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: MRSA bacteremia, epidural abscess.\n\n CHEST: A single AP upright portable chest film at 20:15 is compared to the\n previous examination of . There is further resolution of\n pulmonary edema since the previous examination of . The\n lungs are otherwise clear. There is cardiomegaly with ectatic descending\n aorta. There is no visible left pleural effusion. The right costophrenic\n sulcus is not included on the film. Since the previous exam, the endotracheal\n tube has been removed. There is a left subclavian line with tip in proximal\n SVC.\n\n The patient is status post median sternotomy and CABG.\n\n IMPRESSION: Further resolution of interstitial edema since the previous exam\n four days ago, persistent cardiomegaly.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2135-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890060, "text": " 4:57 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: post intubation\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o MRSA bacteremia and epidural abscess, aspiration\n with persistent low grade fevers now growing Acenitobacter in sputum,\n decreased O2 Sats 85%RA\n REASON FOR THIS EXAMINATION:\n post intubation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, \n\n HISTORY: MRSA bacteremia and low-grade fever. Hypoxia.\n\n IMPRESSION: AP chest compared to 3:25 a.m. today and :\n\n Endotracheal tube is in standard placement. Widespread micronodular pulmonary\n abnormality has progressed since . Findings are most consistent\n with a widespread viral bronchiolitis or hematogenous sepsis. Borderline\n cardiac enlargement is stable while mediastinal venous engorgement has\n increased suggesting increased intravascular volume of pressure. Left\n subclavian line ends centrally. Patient has had an entire thoracic\n laminectomy and median sternotomy. Uppermost sternal wire has been fractured\n for sometime. No pneumothorax. Tiny right pleural effusion may be present.\n Findings were discussed by telephone at the time of dictation with the medical\n house officer covering this patient.\n\n" }, { "category": "Radiology", "chartdate": "2135-10-29 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 888886, "text": " 2:11 AM\n MR W &W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: GADOLINIUM. Please compare appearance of epidural abscess wi\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo with h/o epidural abscess s/p laminectomy and evacuation now with fevers.\n REASON FOR THIS EXAMINATION:\n GADOLINIUM. Please compare appearance of epidural abscess with and\n MRI scans (new abnormality noted on )\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE THORACIC SPINE\n\n CLINICAL INFORMATION: The patient with history of epidural abscess, for\n followup.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images\n were obtained before gadolinium. T1 sagittal and axial images were obtained\n following gadolinium. Comparison was made with the previous thoracic spine\n MRI examination of .\n\n FINDINGS:\n\n Again, extensive laminectomies are seen in the thoracic region. Since the\n previous MRI study, the enhancement and the fluid collection in the posterior\n soft tissues in the upper thoracic region have considerably decreased. There\n is no evidence of abnormal fluid collection seen within the spine. A small\n disc herniation at T11-12 level is again noted. There is no evidence of\n increased signal seen within the spinal cord. The paraspinal soft tissues are\n unremarkable, without evidence of fluid collection.\n\n IMPRESSION: Since the previous MRI of , there has been further\n decrease in fluid collection at the upper portion of the laminectomy site as\n well as the enhancement and soft tissue changes at the laminectomy site. No\n new abnormalities are seen. Specifically, there is no evidence of new\n intraspinal abscess or fluid collection seen, nor there is evidence of\n increased signal within the spinal cord.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-11-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 890144, "text": " 2:29 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: RESP FAILURE/NEW NODULAR INFILTRATES ON CXR\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with respiratory failure, possible aspiration pneumonia, CXR\n read as possible septic emboli.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia, evidence of septic emboli\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, possible aspiration pneumonia.\n\n TECHNIQUE: Multidetector CT images of the chest were obtained without\n intravenous contrast.\n\n COMPARISON: torso CT.\n\n CHEST CT WITHOUT IV CONTRAST: There is no axillary or mediastinal\n lymphadenopathy. Extensive aortic and coronary calcifications are present.\n The heart is moderately enlarged. There are diffuse bilateral ground-glass\n opacities, predominantly in a central distribution. Several irregular\n scattered nodular opacities are present, predominantly in a bronchovascular\n distribution. These are seen in the right upper lobe and left lower lobe.\n Basilar atelectasis is present. There are small bilateral pleural effusions.\n The effusion on the right has increased in size in the interval.\n\n The patient is status post thoracic laminectomy. Soft tissue density is\n present in that area, but has decreased in the interval. No gas bubbles are\n seen.\n\n Visualization of the upper abdominal organs reveals a gastrostomy tube. No\n other abnormalities are seen.\n\n IMPRESSION:\n\n 1. Diffuse central ground-glass opacities with bilateral pleural effusions\n and enlarged heart, consistent with congestive heart failure and pulmonary\n edema.\n\n 2. Multiple ill-defined parenchymal nodular opacities, concerning for a\n superimposed infectious process.\n\n 3. Post-surgical changes in the laminectomy bed, improved from the prior\n study. If detailed evaluation of this region is needed, an MRI is\n recommended.\n\n (Over)\n\n 2:29 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: RESP FAILURE/NEW NODULAR INFILTRATES ON CXR\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2135-10-25 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 888459, "text": " 6:28 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: infiltrate, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p epidural abcess, MRSA bacteremia now with fever\n REASON FOR THIS EXAMINATION:\n infiltrate, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Epidural abscess, MRSA bacteremia, now with fever.\n\n COMPARISON: Radiograph dated .\n\n AP UPRIGHT VIEW OF THE CHEST: There is stable cardiomegaly. A left-sided\n PICC is in satisfactory position. The patient is status post CABG. Lungs are\n grossly clear. No pneumothorax identified. No definite pleural effusion is\n seen.\n\n IMPRESSION: No definite evidence of pneumonia.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-10-31 00:00:00.000", "description": "Report", "row_id": 1375233, "text": "ADMISSION NOTE/CONDITION UPDATE:\nD/A: PT FROM FLOOR WITH WORSENING RESP STATUS, ? ASPIRATION. UPON ARRIVAL, LETHARGIC, VSS, SHALLOW BREATHING.\n\nNEURO: BEFORE INTUBATION, OPENED EYES TO SPEECH, DID NOT FOLLOW COMMANDS, DID NOT SPONTANEOUSLY MOVE EXTREMITIES, MINIMAL TO NO WITHDRAWL TO PAINFUL STIMULI. PERL. PT WAS GIVEN TOTAL OF 2 MG ATIVAN FOR INTUBATION PER MICU TEAM. PT NOW SEDATED.\n\nCV: HR ~ 115 AFIB. ALINE PLACED. ABP ~ 125/60. CENTRAL LINE PLACED, CVP ~ 17. LR 500 CC BOLUS GIVEN X1, NOW ON KVO. NO PEDAL PULSES. MULTIPLE AMPUTATED TOES. CHEST XRAY DONE WITH RESULTS PENDING TO CONFIRM PLACEMENT ON CENTRAL LINE.\n\nRESP: LS SHALLOW BUT CLEAR PRIOR TO INTUBATION, CLEAR POST INTUBATION. ETT POSITION CONFIRMED VIA XRAY. THICK TAN SECREATIONS. TO OBTAIN SPUTUM SAMPLE. ABG ON AC, 100%, 14X500, 5 PEEP: 7.22, 63, 344, 27, -3, 98. VENT CHANGES MADE. TO CHECK ABG IN ~ 1/2 HOUR.\n\nGI: G TUBE IN PLACE, ASPIRIATED TUBE FEEDS OUT TUBE PRIOR TO INTUBATION. + BS. NO VOMITING. NO BM. ABDOMEN SOFT.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE. CREATININE 3.5.\n\nSKIN: FEET WITH NECROTIC AREAS, SCABBED, MULTIPLE TOES AMPUTATED. BACK AND BUTTOCKS UNREMARKABLE.\n\nSX: FAMILY IS UPDATED AND AWARE OF ICU ENVIRONMENT. SPOKE WITH MICU TEAM ABOUT EVENTS AND PLAN.\n\nR: LOW GRADE TEMP, VSS, WITH CONCERNING RESPIRATORY STATUS.\n\nP: CONTINUE CURRENT CLOSE MONITORING AND MANGEMENT. PT AND FAMILY SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-11-01 00:00:00.000", "description": "Report", "row_id": 1375234, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear suct sm th white sput. ABGs slowly resolving resp acidosis with good oxygenation; no vent changes required. Cont mech vent support.\n" } ]

[ { "category": "Physician ", "chartdate": "2141-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377076, "text": "TITLE:\n Chief Complaint: Pleuritic right chest pain\n 24 Hour Events:\n - patient started on coumadin\n - UOP briefly decreased (although unclear whether this was due to\n accidental foley removal), UOP responded appropriately to 500 ml LR\n bolus\n S: The patient is feeling well. Her chest pain has entirely resolved.\n She continues to have dry-mouth as well as her baseline amount of cough\n and shortness or breath. She has not had N/V diarrhea. No pain or\n swelling in her legs.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Heparin Sodium - 850 units/hour\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 07:16 AM\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: 36.4\nC (97.6\n HR: 80 (73 - 94) bpm\n BP: 99/55(67) {82/37(35) - 125/73(89)} mmHg\n RR: 18 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,315 mL\n 690 mL\n PO:\n 270 mL\n 60 mL\n TF:\n IVF:\n 2,045 mL\n 630 mL\n Blood products:\n Total out:\n 700 mL\n 250 mL\n Urine:\n 700 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,615 mL\n 440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortable\n HEENT: dry MMM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds throughout, lungs otherwise clear\n Abd: Soft, non-tender, +bowel sounds\n Ext: Warm and well-perfused, no edema or tenderness\n Neuro: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 293 K/uL\n 8.1 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 143 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n WBC\n 10.6\n 8.3\n Hct\n 24.7\n 25.0\n Plt\n 269\n 293\n Cr\n 0.8\n 0.6\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n Other labs: PT / PTT / INR:15.3/56.2/1.3, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.3 mg/dL, Mg++:2.0\n mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - continue heparin drip\n - continue close monitoring of hemodynamic status\n - will increase coumadin to 5 mg today and recheck INR\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - has completed mini-stress dose steroids for possible component of\n adrenal insufficiency in this patient on long term steroid therapy,\n transition back to home dose of prednisone 5 mg daily\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: Low-sodium diet\n Glycemic Control: Patient has been euglycemic, continue monitoring\n with daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: Likely call out to medical floor later today\n" }, { "category": "Physician ", "chartdate": "2141-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377080, "text": "TITLE:\n Chief Complaint: Pleuritic right chest pain\n 24 Hour Events:\n - patient started on coumadin\n - UOP briefly decreased (although unclear whether this was due to\n accidental foley removal), UOP responded appropriately to 500 ml LR\n bolus\n S: The patient is feeling well. Her chest pain has entirely resolved.\n She continues to have dry-mouth as well as her baseline amount of cough\n and shortness or breath. She has not had N/V diarrhea. No pain or\n swelling in her legs.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Heparin Sodium - 850 units/hour\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 07:16 AM\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: 36.4\nC (97.6\n HR: 80 (73 - 94) bpm\n BP: 99/55(67) {82/37(35) - 125/73(89)} mmHg\n RR: 18 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,315 mL\n 690 mL\n PO:\n 270 mL\n 60 mL\n TF:\n IVF:\n 2,045 mL\n 630 mL\n Blood products:\n Total out:\n 700 mL\n 250 mL\n Urine:\n 700 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,615 mL\n 440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortable\n HEENT: dry MMM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds throughout, lungs otherwise clear\n Abd: Soft, non-tender, +bowel sounds\n Ext: Warm and well-perfused, no edema or tenderness\n Neuro: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 293 K/uL\n 8.1 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 143 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n WBC\n 10.6\n 8.3\n Hct\n 24.7\n 25.0\n Plt\n 269\n 293\n Cr\n 0.8\n 0.6\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n Other labs: PT / PTT / INR:15.3/56.2/1.3, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.3 mg/dL, Mg++:2.0\n mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - continue heparin drip\n - continue close monitoring of hemodynamic status\n - will increase coumadin to 5 mg today and recheck INR\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - continue vancomycin, ciprofloxacin for total course of 7 days\n - obtain sputum sample for culture to help narrow antibiotic coverage\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been at at her usual BP (per outpatient OMR\n notes) of systolics between high-80\ns to low 110\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\nHYPONATREMIA: Patient with Na at nadir value of 133 (down from 138) at\n 4am on , likely dilutional given substantial amount of NS she\n received since admission. Fluids switched to LR\n HYPOKALEMIA:\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: Low-sodium diet\n Glycemic Control: Patient has been euglycemic, continue monitoring\n with daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: Likely call out to medical floor later today\n" }, { "category": "Echo", "chartdate": "2141-07-19 00:00:00.000", "description": "Report", "row_id": 61500, "text": "PATIENT/TEST INFORMATION:\nIndication: r/o RV dysfunction.; Tachycardia and hypotension. COPD.\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 99/54\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:27\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: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Increased IVC diameter (>2.1cm) with <35% decrease\nduring respiration (estimated RA pressure (10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Low\nnormal LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild to moderate\n(+) MR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 10-20mmHg. Left ventricular\nwall thicknesses and cavity size are normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is low normal (LVEF 50-55%). There is no\nventricular septal defect. The right ventricular cavity is mildly dilated with\nnormal free wall contractility. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. The pulmonary artery systolic pressure could\nnot be determined. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the degree of\nMR has decreased. The LV and RV look similar.\n\n\n" }, { "category": "Physician ", "chartdate": "2141-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377129, "text": "TITLE:\n Chief Complaint: Pleuritic right chest pain\n 24 Hour Events:\n - patient started on coumadin\n - briefly decreased (although unclear whether this was due to\n accidental foley removal), responded appropriately to 500 ml LR\n bolus with 60-70 cc\ns per hour this am\n - patient briefly developed non-gap acidosis with bicarb of 19,\n resolved with substitution of LR for NS for fluid boluses\n S: The patient is feeling well. Her chest pain has entirely resolved.\n She continues to have dry-mouth as well as her baseline amount of cough\n and shortness or breath. She has not had N/V diarrhea. No pain or\n swelling in her legs.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Heparin Sodium - 850 units/hour\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 07:16 AM\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: 36.4\nC (97.6\n HR: 80 (73 - 94) bpm\n BP: 99/55(67) {82/37(35) - 125/73(89)} mmHg\n RR: 18 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,315 mL\n 690 mL\n PO:\n 270 mL\n 60 mL\n TF:\n IVF:\n 2,045 mL\n 630 mL\n Blood products:\n Total out:\n 700 mL\n 250 mL\n Urine:\n 700 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,615 mL\n 440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortable\n HEENT: dry MMM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds throughout, lungs otherwise clear\n Abd: Soft, non-tender, +bowel sounds\n Ext: Warm and well-perfused, no edema or tenderness\n Neuro: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 293 K/uL\n 8.1 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 143 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n WBC\n 10.6\n 8.3\n Hct\n 24.7\n 25.0\n Plt\n 269\n 293\n Cr\n 0.8\n 0.6\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n Other labs: PT / PTT / INR:15.3/56.2/1.3, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.3 mg/dL, Mg++:2.0\n mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - transition from heparin drip to lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - will d/c abx today given her excellent clinical response to treatment\n of PE and clinical appearance not consistent with bacterial pneumonia\n - obtain sputum sample for culture in the event that patient spikes a\n fever\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been at at her usual BP (per outpatient OMR\n notes) of systolics between high-80\ns to low 110\n - continue fluid bolus to goal SBP >90, >30 cc/hr\nOLIGURIA: It is unclear whether the low recorded overnight was\n truly oliguria or due to the foley being accidentally removed;\n regardless her has been satisfactory since this receiving a 500 cc\n LR bolus. Creatinine of 0.6 suggests good renal function\n -d/c foley, encourage PO intake\n - monitor I\ns and O\nHYPONATREMIA: Patient with Na at nadir value of 133 (down from 138) at\n 4am on , likely dilutional given substantial amount of NS she\n received since admission. Has improved overnight with decreasing\n frequency of fluid boluses.\n - check lytes daily\n HYPOKALEMIA: Patient has refused PO K repletion, therefore will\n continue to slowly infuse IV K so as to avoid pain at infusion site.\n Patient\ns daughter reports that she takes her own K supplementation at\n home; if her daughter brings this in she can take this form of PO K\n instead.\n - check pm K\nNON-GAP ACIDOSIS: Likely due to hydration with large volumes of NS.\n Has improved with changing fluids to LR.\n - continue LR for fluids\n - check lytes daily\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - switch heparin drip to lovenox \n ANEMIA: Stable at patient\ns baseline Hct in mid-to-high 20\n - check Hct daily\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 likely due to large PE.\n - wean O2 as tolerated\n - continue home COPD meds\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x3. Echo yesterday showed\n ventricular size and function largely unchanged from previous echo.\n - continue home meds\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: Low-sodium diet\n Glycemic Control: Patient has been euglycemic, continue monitoring\n with daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: Likely call out to medical floor later today\n 13:28\n ------ Protected Section ------\n Agree with excellent MS4 Note.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:19 ------\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377137, "text": "Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns postivie for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on Heparin gtt at 850 units/hr, d\ncd at 12 noon, pt on Lovenox 60\n mg sc q 12 hrs, and Coumadin 3 mg po qd continues. Pt with DVT\ns, and\n PE. Rr 24-34 repeat CXR done\n pending. tachypeic with\n exertion. Pt oob to chair, took a few steps\n Action:\n Pt switched to Lovenox\n Response:\n Plan:\n Continue to monitor INR monitor resp status. ?call out to 5S\n tomorrow.\n Hypotension (not Shock)\n Assessment:\n Bp stable 95-116/50-60 HR 90-110 ST. DP/PT doppler foley\n intact\n pt received 20 mg IVP lasix (pt + 5 liters)\n Action:\n 20 mg IVP lasix given pt received 40 meq kcl IV for k~3.2\n Response:\n Good response to lasix\n Plan:\n Continuet o monitor hemodynamic status closely. follow I+O\n closely. repeat k sent\n ID: temp 100.9 po, blood cultures x 2, urine and sputum cx\ns sent.\n 650 mg po Tylenol given at 1630\n SOCIAL: full code, pt called back in (was called out to 5South)\n called back in secondary to elevated HR, temp up, pt anxious, fluid\n overloaded.\n NEURO: A+OX3, as day progressed, pt becoming increasily anxious.\n Received 0.5 mg PO Ativan with good affect. Pt able to sleep in short\n naps.\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377141, "text": "Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n TEE one ~ showed L and R ventricles to be largely unchanged from\n pt\ns previous echo. PE likely due to prolonged immobilization with\n inadequate anticoagulation. on Heparin gtt at 850 units/hr, d\ncd at\n 12 noon, pt on Lovenox 60 mg sc q 12 hrs, and Coumadin 3 mg po qd\n continues. Pt with DVT\ns, and PE. RR 24-34 repeat CXR done\n small amount of pulm edema. tachypeic with exertion. Pt oob to chair,\n took a few steps\n Pt on Spiriva, Advair, 5 mg po Prednisone, 10 mg Singular, with\n chronic cough\n Benzonatate increased to 200 mg po tid, and received 10\n cc\ns Guifenesin-Codeine for cough\n. Also received Levalbuterol\n neb. Pt with good cough\n using yankar suction\n coughing up tan\n secretions. Lungs with decreased breath sounds..\n Action:\n Pt switched to Lovenox, on Coumadin.\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. ?call out to 5S\n tomorrow. Give prn Guifenesin-Codeine and Ativan prn.\n Hypotension (not Shock)\n Assessment:\n Bp stable 95-116/50-60 HR 90-110 ST. DP/PT doppler foley\n intact\n pt received 20 mg IVP lasix (pt + 5 liters) (per OMR notes\n pt has systolic bp\ns between high-80\ns to low 110\n Action:\n 20 mg IVP lasix given pt received 40 meq kcl IV for k~3.2\n Response:\n Good response to lasix\n Plan:\n Continue to monitor hemodynamic status closely. follow I+O\n closely. repeat k sent\n ID: antibx d\ncd on rounds.. WBC 8.3 afebrile then temp 100.9\n po, blood cultures x 2, urine and sputum cx\ns sent. 650 mg po\n Tylenol given at 1630\n SOCIAL: full code, pt called back in (was called out to 5South)\n called back in secondary to elevated HR, temp up, pt anxious, fluid\n overloaded.\n NEURO: A+OX3, as day progressed, pt becoming increasily anxious.\n Received 0.5 mg PO Ativan with good affect. Pt able to sleep in short\n naps. OOB to chair\n took a few steps, needed assistance\n pt weak\n" }, { "category": "Physician ", "chartdate": "2141-07-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 376857, "text": "Chief Complaint: R pleuritic chest pain, fever\n HPI:\n This is a 81 yo F with h/o chronic eosinophilic lung disease, COPD\n (FEV1 0.74, FEV1/FVC 72% predicted in ), diastolic CHF, atrial\n fibrillation/atrial tachycardia, and HTN with recent hospitalization at\n from - for MSSA and Psueodmonas RLL PNA requiring\n intubation, pressor support for hypotension, L sided PTX, and C diff\n colitis who presents from her nursing home with fever and increasing\n right sided pleuritic chest pain. Pt describes sudden onset of lower\n right sided pleuritic chest pain yesterday that was non-radiating,\n . Feels SOB at baseline and does not feel SOB is significantly\n worse from baseline although she feels she is unable to take as deep of\n a breath than usual. The pt also describes a chronic cough for years\n that has not changed. The pt also complains of subjective and objective\n fevers, up to 101 at rehab 2 days ago. Denies diarrhea but describes\n some increased abdominal distention. No nausea, vomiting, neck pain,\n photophobia, increasing confusion, dysuria, urinary frequency.\n .\n In the ED, Tm 103.4, BP 89/42, HR 126, RR 27, O2 sat 98% RA. Labs\n notable for WBC 10.5 without bands, Hct 32.2 (prior baseline mid to\n upper 20s), Cr 0.9, CE neg X 1, and lactate 1.5. EKG with sinus\n tachycardia and no signs of right sided heart strain. CXR with RLL\n infiltrate. Chest CTA preliminarily read as extensive right sided PE\n with RLL infiltrate possibly concerning for infarcted lung. She was\n started on heparin gtt with bolus, given Vancomycin 1 gm IV X 1,\n Cefepime 1 gm IV X 1, and acetaminophen 1 gm po X 1. Admitted to \n for further care.\n .\n ROS as above. Otherwise notable for some increased fatigue. Denies\n myalgias, sore throat, recent travel. Has been in rehab for past month.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -h/o C. diff colitis\n -h/o MSSA PNA\n -AF/AT\n -COPD\n -diastolic CHF, EF 55%\n -Osteoarthritis\n -H/o myocarditis in with EF 20-25% at that time, cath negative\n -Hyperlipidemia\n -Peripheral artery disease\n -HTN\n -Migraine HA\n -Chronic eosinophilic lung disease (chronic eosinophilic pneumonia or\n Churg- syndrome)\n -Hypoalbuminemia\n -History of angioneurotic edema on therapy\n n/c\n Occupation: retired\n Drugs:\n Tobacco: former, quit 30 years ago\n Alcohol: denies\n Other: currently resides at rehab, although was living at home with\n daughter prior to most recent hospitalization\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, R pleuritic chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: abdominal distention\n Genitourinary: Foley\n Flowsheet Data as of 06:35 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: 85 (85 - 128) bpm\n BP: 88/54(62) {85/42(47) - 88/54(62)} mmHg\n RR: 19 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 2,522 mL\n PO:\n TF:\n IVF:\n 522 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 2,022 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: No(t) Sclera edema, dry MM\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no m/r/g\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: Clear : , Diminished: decreased\n air mvmt throughout), no w/r/r\n Abdominal: Soft, Non-tender, Bowel sounds present, mild-mod abdominal\n distention\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, cap refill < 2 sec\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place, time, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 322\n 10.3\n 115\n 0.9\n 12\n 26\n 103\n 4.2\n 138\n 32.2\n 10.5\n [image002.jpg]\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n 81 yo F with h/o chronic eosinophilic lung disease, COPD, diastolic\n CHF, and recent admission for MSSA and pan-sensitive Pseudomonas PNA\n who presents with fev--ers, right sided pleuritic chest pain and found\n to have extensive R sided PE on imaging.\n .\n #) Pulmonary embolism - Per preliminary report on chest CTA, PE with\n extensive involvement on right side. At the moment, pt without\n significant hypoxia; however pt is tachycardic and hypotensive. This\n may be hemodynamic effects from PE vs. development of infection/sepsis.\n Arguing against significant hemodynamic effect of PE and sepsis is\n relatively normal lactate, suggestive effective tissue perfusion. In\n regards to precipitating factors of PE, pt without known h/o\n malignancy, no known genetic thrombotic risk factors (Factor V Leidin,\n antiphospholipid Ab, etc). She has had recent prolonged hospitalization\n and subsequent rehab --> immobilization but has been ordered for\n heparin SQ prophylaxis at rehab.\n - Continue anticoagulation with heparin gtt with PTT goal 60-80.\n - Follow-up final read of chest CTA.\n - Check TTE.\n - Check bilateral LENIs.\n - If TTE with signs of right heart strain or develops worsening\n hemodynamics, would consult vascular surgery vs. interventional\n cardiology regarding possibility of administration of local\n thrombolytics.\n - Will need eventual bridge to coumadin.\n .\n #) Fever - In setting of tachycardia and hypotension thus meeting\n criteria for SIRS although this is clouded by the fact that tachycardia\n and hypotension may also be PE (see above). Unlikely that clot\n burden would cause this degree of fevers. She does have RLL infiltrate\n on CXR and chest CTA; however, by CXR this appears to be improving from\n last hospitalization. Recently completed 2 week course of po vancomycin\n for C. diff colitis.\n - f/u blood, urine cxs.\n - If has frequent stools, will recheck C. diff toxin titers, although\n titers may still be positive after successfully treated course of C.\n diff.\n - Continue antibiotic coverage with IV vancomycin, po cipro (had\n pan-sensitive Psuedomonas last hospitalization) for now given risk\n factors for HAP and RLL infiltrate. If spikes further fevers, will\n broaden GNR/Pseudomonas coverage.\n - Obtain sputum cx.\n - Will bolus IVFs to maintain SBPs > 90, urine output > 30 cc/hr, MS\n changes.\n .\n #) Hypotension - In setting of new diagnosis of PE and possible\n sepsis/infection. Pt is on chronic steroids at baseline for COPD.\n - Stress dose steroids for now at hydrocortisone 50 mg IV q8h.\n - Monitor BPs closely. No need for a-line yet, but if requires\n pressors, will place.\n - Bolus IVFs as above for SBP < 90.\n .\n #) ST depressions - Possibly secondary to decreased leftward forward\n flow in setting of large R sided PE. Doubt primary ACS. Pt's CP is not\n typical of usual ACS-type chest pain. Initial CE negative X 1.\n - Will cycle CEs X 3.\n - Continue aspirin, statin. Holding b-blocker given hypotension.\n - Already on heparin gtt for PE.\n - Obtain am EKG.\n .\n #) h/o C diff colitis - Recently completed po vancomycin course as\n above and saw Dr. in clinic who recommended at least 1\n month of probiotics.\n - If frequent loose stools, will send for c. diff as above.\n - Hold on restarting C. diff treatment for now.\n - Florastor 500 mg , if on formulary.\n .\n #) h/o COPD - Currently does not appear to have signs/sxs suggestive of\n COPD exacerbation.\n - Continue levalbuterol nebs prn, ipratropium nebs.\n - Increasing to stress dose steroids as above.\n .\n #) Diastolic CHF - No signs of volume overload currently on exam.\n - Hold beta-blocker for now given relative hypotension.\n .\n #) h/o afib/AT - Currently in sinus tachycardia. Holding beta-blocker\n as above given concern for hypotension.\n .\n #) h/o chronic eosinophilic lung disease - Not known to be currently\n active.\n .\n #) PVD - Continue aspirin.\n .\n #) Hyperlipidemia - Continue statin.\n .\n #) FEN/GI - low Na, heart healthy, replete lytes prn\n #) Ppx - On heparin gtt. Continue outpt dose of pantoprazole.\n #) Code - full code, verified with pt\n #) Communication - with pt and family\n #) Access - 1 16 G PIV, 1 20 G PIV\n #) Dispo - ICU level of care for now. Possible callout to floor if HDs\n improve.\n ICU Care\n Nutrition:\n Comments: low Na, heart healthy diet\n Glycemic Control:\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Comments: communication with pt and family\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376878, "text": "Chest Pain: pt admitted with report of right sided chest pain, now\n resolved, trending CE, first two sets flat, third pending with am labs,\n f/u CE, continue to monitor for CP\n Afib: pt in Afib with a rate of 130s on admission from EW, found to be\n in NSR at change of shift, remained in SR throughout the shift, pt with\n hx of Afib has never been anticoagulated in that past\n Pulmonary Embolism (PE), Acute\n Assessment:\n CT yesterday with extensive right PE, pt on heparin gtt, LENIs\n yesterday day with bilat DVTs\n Action:\n Q6hr ptt, titrating heparin infusion per protocol, pt NPO except meds\n after midnight\n Response:\n Ptt supratherapeutic with evening draw, am labs pending\n Plan:\n Continue hep gtt, ?IVC filter placement today plan per resident though\n orders pending\n Hypotension (not Shock)\n Assessment:\n BP: 83-118/47-57, baseline BP 90-115 systolic\n Action:\n Given 2 500 cc NS boluses\n Response:\n Responding to fluid boluses, borderline u/o\n Plan:\n Continue to monitor, continue to treat with fluid boluses\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt maintaining sats of 2 L NC, breath sounds dim throughout, persistent\n cough chronic per patient report, productive at times though largely\n dry\n Action:\n Treating cough with guiafenisin/codiene, given trazadone\n Response:\n Pt with no relief to cough, awake most of night\n Plan:\n Continue to monitor, titrate supplemental O2 as tolerated\n" }, { "category": "Nursing", "chartdate": "2141-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376879, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis, mssa\n pneumonia, afib, at, copd, chf with ef of 55%, osteoarthritis, pad,\n htn, migraine ha, chronic eosinophilic lung disease and hypoalbenemia.\n She presented to ed from nursing home with c/o fever, cough,\n recent infection and pleuritic r sided rib pain. Ct c/w extensive r pe,\n rll opacification concerning for pulm infection. Pt\ns usual bp runs\n 90-115. in ed temp=103 and sbp 80\ns. pt given Vancomycin, Cefepime and\n Tylenol. Bolused with 1 liter ns and given bolus of 4900 units heparin\n iv and gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n Chest Pain: pt admitted with report of right sided chest pain, now\n resolved, trending CE, first two sets flat, third pending with am labs,\n f/u CE, continue to monitor for CP\n Afib: pt in Afib with a rate of 130s on admission from EW, found to be\n in NSR at change of shift, remained in SR throughout the shift, pt with\n hx of Afib has never been anticoagulated in that past\n Pulmonary Embolism (PE), Acute\n Assessment:\n CT yesterday with extensive right PE, pt on heparin gtt, LENIs\n yesterday day with bilat DVTs\n Action:\n Q6hr ptt, titrating heparin infusion per protocol, pt NPO except meds\n after midnight\n Response:\n Ptt supratherapeutic with evening draw, am labs pending\n Plan:\n Continue hep gtt, ?IVC filter placement today plan per resident though\n orders pending, continue q6hr ptt next to be drawn at 1000\n Hypotension (not Shock)\n Assessment:\n BP: 83-118/47-57, baseline BP 90-115 systolic\n Action:\n Given 2 500 cc NS boluses\n Response:\n Responding to fluid boluses, borderline u/o\n Plan:\n Continue to monitor, continue to treat with fluid boluses\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt maintaining sats of 2 L NC, breath sounds dim throughout, persistent\n cough chronic per patient report, productive at times though largely\n dry\n Action:\n Treating cough with guiafenisin/codiene, given trazadone\n Response:\n Pt with no relief to cough, awake most of night\n Plan:\n Continue to monitor, titrate supplemental O2 as tolerated\n" }, { "category": "Nursing", "chartdate": "2141-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377006, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis, mssa\n pneumonia, afib, at, copd, chf with ef of 55%, osteoarthritis, pad,\n htn, migraine ha, chronic eosinophilic lung disease and hypoalbenemia.\n She presented to ed from nursing home with c/o fever, cough,\n recent infection and pleuritic r sided rib pain. Ct c/w extensive r pe,\n rll opacification concerning for pulm infection. Pt\ns usual bp runs\n 90-115. in ed temp=103 and sbp 80\ns. pt given Vancomycin, Cefepime and\n Tylenol. Bolused with 1 liter ns and given bolus of 4900 units heparin\n iv and gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on heparin gtt. BBS diminished t/o, and pt c/o frequent\n cough; however, denies SOB, reports cough has been unchanged over past\n several years, remains free of s/s distress. SpO2 98-100% on\n supplemental O2 2L via NC.\n Action:\n Monitoring respiratory status closely. PTT therapeutic at noon. Repeat\n PTT at 1800. Pt began heparin to coumadin therapy\n given coumadin 3mg\n PO at 1600 as ordered. Pt/family teaching re: coumadin initiated. Pt\n teaching handout provided.\n Response:\n Respiratory status stable. SpO2 remains 98-100% on 2L via NC. BBS\n diminished t/o. Pt continues w/ cough; however, denies changes in\n cough, denies SOB and remains free of diaphoresis or distress. Pt has\n continued to deny pain t/o shift. Cardiac enzymes have been negative\n times three sets.\n Plan:\n Continue to monitor respiratory status closely. Continue heparin to\n coumadin therapy. Monitor PTT q6hr. Monitor INR daily. Reinforce\n pt/family teaching re: coumadin therapy.\n Hypotension (not Shock)\n Assessment:\n Baseline SBP 90\ns. SBP has remained 80\ns to 90\ns w/ UOP borderline. Pt\n remains A+OX3, denies dizziness. Remains free of diaphoresis or\n distress.\n Action:\n Monitoring hemodynamic status closely. Pt given NS 500ml IVF bolus X 1\n LR 500ml IVF bolus X 1. UOP increases s/p IVF bolus. Urine specimen\n sent for U/A and urine lytes as ordered. PO fluids encouraged.\n Response:\n UOP >30ml/hr w/ IVF as above. w/ SBP 90\ns to low 100\ns (see flowsheet).\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for IVF\n if UOP <30ml/hr.\n" }, { "category": "Nursing", "chartdate": "2141-07-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 377245, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, Currently afebrile. Tmax 98.7 oral . TEE one ~ showed L\n and R ventricles to be largely unchanged from pt\ns previous echo. PE\n likely due to prolonged immobilization with inadequate\n anticoagulation. Was on heparin gtt until 12 noon. currently on\n Lovenox 60 mg sc q 12 hrs, and Coumadin 3 mg po daily. LS with rhonchi\n , diminished at bases. Spo2 above 95% on 2LNC. Appears slightly\n tachypneic on exertion although denies any discomfort.\n Occasional productive cough , using yanker suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin.\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. Medicate with prn\n guafenasine with codein and ativan as needed.\n Hypotension (not Shock)\n Assessment:\n HR 90-100 . (per OMR notes\n pt has systolic bp\ns between high-80\ns to\n low 110\ns) BP trending up to 90-100 systolic when aroused. DP/PT\n doppler,U/O around 30-40cc/hr\n Action:\n K+ repleted,pt refused to take the prescribed dose had only 20 mEq,had\n banana with diet.\n Response:\n Haemodinamically remains stable.\n Plan:\n Continue to monitor hemodynamic status closely.\n c/o floor awaiting for bed\n" }, { "category": "Physician ", "chartdate": "2141-07-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 376863, "text": "Chief Complaint: R pleuritic chest pain, fever\n HPI:\n This is a 81 yo F with h/o chronic eosinophilic lung disease, COPD\n (FEV1 0.74, FEV1/FVC 72% predicted in ), diastolic CHF, atrial\n fibrillation/atrial tachycardia, and HTN with recent hospitalization at\n from - for MSSA and Psueodmonas RLL PNA requiring\n intubation, pressor support for hypotension, L sided PTX, and C diff\n colitis who presents from her nursing home with fever and increasing\n right sided pleuritic chest pain. Pt describes sudden onset of lower\n right sided pleuritic chest pain yesterday that was non-radiating,\n . Feels SOB at baseline and does not feel SOB is significantly\n worse from baseline although she feels she is unable to take as deep of\n a breath than usual. The pt also describes a chronic cough for years\n that has not changed. The pt also complains of subjective and objective\n fevers, up to 101 at rehab 2 days ago. Denies diarrhea but describes\n some increased abdominal distention. No nausea, vomiting, neck pain,\n photophobia, increasing confusion, dysuria, urinary frequency.\n .\n In the ED, Tm 103.4, BP 89/42, HR 126, RR 27, O2 sat 98% RA. Labs\n notable for WBC 10.5 without bands, Hct 32.2 (prior baseline mid to\n upper 20s), Cr 0.9, CE neg X 1, and lactate 1.5. EKG with sinus\n tachycardia and no signs of right sided heart strain. CXR with RLL\n infiltrate. Chest CTA preliminarily read as extensive right sided PE\n with RLL infiltrate possibly concerning for infarcted lung. She was\n started on heparin gtt with bolus, given Vancomycin 1 gm IV X 1,\n Cefepime 1 gm IV X 1, and acetaminophen 1 gm po X 1. Admitted to \n for further care.\n .\n ROS as above. Otherwise notable for some increased fatigue. Denies\n myalgias, sore throat, recent travel. Has been in rehab for past month.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -h/o C. diff colitis\n -h/o MSSA PNA\n -AF/AT\n -COPD\n -diastolic CHF, EF 55%\n -Osteoarthritis\n -H/o myocarditis in with EF 20-25% at that time, cath negative\n -Hyperlipidemia\n -Peripheral artery disease\n -HTN\n -Migraine HA\n -Chronic eosinophilic lung disease (chronic eosinophilic pneumonia or\n Churg- syndrome)\n -Hypoalbuminemia\n -History of angioneurotic edema on therapy\n n/c\n Occupation: retired\n Drugs:\n Tobacco: former, quit 30 years ago\n Alcohol: denies\n Other: currently resides at rehab, although was living at home with\n daughter prior to most recent hospitalization\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, R pleuritic chest pain\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: abdominal distention\n Genitourinary: Foley\n Flowsheet Data as of 06:35 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: 85 (85 - 128) bpm\n BP: 88/54(62) {85/42(47) - 88/54(62)} mmHg\n RR: 19 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 2,522 mL\n PO:\n TF:\n IVF:\n 522 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 2,022 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: No(t) Sclera edema, dry MM\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no m/r/g\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: Clear : , Diminished: decreased\n air mvmt throughout), no w/r/r\n Abdominal: Soft, Non-tender, Bowel sounds present, mild-mod abdominal\n distention\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, cap refill < 2 sec\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place, time, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 322\n 10.3\n 115\n 0.9\n 12\n 26\n 103\n 4.2\n 138\n 32.2\n 10.5\n [image002.jpg]\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n 81 yo F with h/o chronic eosinophilic lung disease, COPD, diastolic\n CHF, and recent admission for MSSA and pan-sensitive Pseudomonas PNA\n who presents with fev--ers, right sided pleuritic chest pain and found\n to have extensive R sided PE on imaging.\n .\n #) Pulmonary embolism - Per preliminary report on chest CTA, PE with\n extensive involvement on right side. At the moment, pt without\n significant hypoxia; however pt is tachycardic and hypotensive. This\n may be hemodynamic effects from PE vs. development of infection/sepsis.\n Arguing against significant hemodynamic effect of PE and sepsis is\n relatively normal lactate, suggestive effective tissue perfusion. In\n regards to precipitating factors of PE, pt without known h/o\n malignancy, no known genetic thrombotic risk factors (Factor V Leidin,\n antiphospholipid Ab, etc). She has had recent prolonged hospitalization\n and subsequent rehab --> immobilization but has been ordered for\n heparin SQ prophylaxis at rehab.\n - Continue anticoagulation with heparin gtt with PTT goal 60-80.\n - Follow-up final read of chest CTA.\n - Check TTE.\n - Check bilateral LENIs.\n - If TTE with signs of right heart strain or develops worsening\n hemodynamics, would consult vascular surgery vs. interventional\n cardiology regarding possibility of administration of local\n thrombolytics.\n - Will need eventual bridge to coumadin.\n .\n #) Fever - In setting of tachycardia and hypotension thus meeting\n criteria for SIRS although this is clouded by the fact that tachycardia\n and hypotension may also be PE (see above). Unlikely that clot\n burden would cause this degree of fevers. She does have RLL infiltrate\n on CXR and chest CTA; however, by CXR this appears to be improving from\n last hospitalization. Recently completed 2 week course of po vancomycin\n for C. diff colitis.\n - f/u blood, urine cxs.\n - If has frequent stools, will recheck C. diff toxin titers, although\n titers may still be positive after successfully treated course of C.\n diff.\n - Continue antibiotic coverage with IV vancomycin, po cipro (had\n pan-sensitive Psuedomonas last hospitalization) for now given risk\n factors for HAP and RLL infiltrate. If spikes further fevers, will\n broaden GNR/Pseudomonas coverage.\n - Obtain sputum cx.\n - Will bolus IVFs to maintain SBPs > 90, urine output > 30 cc/hr, MS\n changes.\n .\n #) Hypotension - In setting of new diagnosis of PE and possible\n sepsis/infection. Pt is on chronic steroids at baseline for COPD.\n - Stress dose steroids for now at hydrocortisone 50 mg IV q8h.\n - Monitor BPs closely. No need for a-line yet, but if requires\n pressors, will place.\n - Bolus IVFs as above for SBP < 90.\n .\n #) ST depressions - Possibly secondary to decreased leftward forward\n flow in setting of large R sided PE. Doubt primary ACS. Pt's CP is not\n typical of usual ACS-type chest pain. Initial CE negative X 1.\n - Will cycle CEs X 3.\n - Continue aspirin, statin. Holding b-blocker given hypotension.\n - Already on heparin gtt for PE.\n - Obtain am EKG.\n .\n #) h/o C diff colitis - Recently completed po vancomycin course as\n above and saw Dr. in clinic who recommended at least 1\n month of probiotics.\n - If frequent loose stools, will send for c. diff as above.\n - Hold on restarting C. diff treatment for now.\n - Florastor 500 mg , if on formulary.\n .\n #) h/o COPD - Currently does not appear to have signs/sxs suggestive of\n COPD exacerbation.\n - Continue levalbuterol nebs prn, ipratropium nebs.\n - Increasing to stress dose steroids as above.\n .\n #) Diastolic CHF - No signs of volume overload currently on exam.\n - Hold beta-blocker for now given relative hypotension.\n .\n #) h/o afib/AT - Currently in sinus tachycardia. Holding beta-blocker\n as above given concern for hypotension.\n .\n #) h/o chronic eosinophilic lung disease - Not known to be currently\n active.\n .\n #) PVD - Continue aspirin.\n .\n #) Hyperlipidemia - Continue statin.\n .\n #) FEN/GI - low Na, heart healthy, replete lytes prn\n #) Ppx - On heparin gtt. Continue outpt dose of pantoprazole.\n #) Code - full code, verified with pt\n #) Communication - with pt and family\n #) Access - 1 16 G PIV, 1 20 G PIV\n #) Dispo - ICU level of care for now. Possible callout to floor if HDs\n improve.\n ICU Care\n Nutrition:\n Comments: low Na, heart healthy diet\n Glycemic Control:\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Comments: communication with pt and family\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Critical Care\n Present for the key portions of the history and exam. Agree\n substantially with assessment and plan as outlined above. 81 yo with\n COPD, chronic eosinophilic PNA, diastolic CHF, AFib, and HTN recent\n discharged after hosp 1 mo ago for Pseudomonas PNA with course c/b C\n diff colitis. Doing well in rehab when R pleuritic CP and fever over\n 2d with temp as high as 101. Sent to ED for eval\n CTA done\n submassive PE R main PA and Pmiddle and lower branches. T to 103, BP\n 89s and HR 126. Heparinized and adm to .\n 98.7 125 to 88 after 500 cc bolus 88/54\n Alert\n No rub diminished BS\n w/o cord\n WBC 10.5\n Signif PE in a woman with multiple med problems. She is mildly\n hypotensive but has responded to fluid and is making urine. With\n improving HR in response to fluid will bolus her further. I am not\n inclined to use TPA unless signs of hypoperfusion (decr UO, incr\n lactate). Fever is high for PE and we are culturing although seems\n likely this is a unitary dx.\n Time spent 40 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 19:23 ------\n" }, { "category": "Nursing", "chartdate": "2141-07-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376851, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis,mssa\n pneumonia, afib,at, copd,chf with ef of 555,osteoarthritis, pad, htn,\n migraine ha, chronic eosinophilic lung disease and hypoalbenemia. She\n presented to ed with c/o fever, cough, recent infection and\n pleuritic r sided rib pain. Ct c/w extensive r pe, rll opacification\n concerning for pulm infection. Pt\ns usual bp runs 90-115. in ed\n temp=103 and sbp 80\ns. pt given Vancomycin,cefepime and Tylenol.\n Bolused with 1 liter ns and given bolus of 4900 units heparin iv and\n gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n" }, { "category": "Nursing", "chartdate": "2141-07-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376853, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis,mssa\n pneumonia, afib,at, copd,chf with ef of 555,osteoarthritis, pad, htn,\n migraine ha, chronic eosinophilic lung disease and hypoalbenemia. She\n presented to ed with c/o fever, cough, recent infection and\n pleuritic r sided rib pain. Ct c/w extensive r pe, rll opacification\n concerning for pulm infection. Pt\ns usual bp runs 90-115. in ed\n temp=103 and sbp 80\ns. pt given Vancomycin,cefepime and Tylenol.\n Bolused with 1 liter ns and given bolus of 4900 units heparin iv and\n gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt transferred to from ed with diagnosis of acute extensive r\n pulm emboli. Pt with sbp 85-88 and rr in the mid 20\ns. presently\n afebrile. c/o r sided pleuritic rib pain with deep breath. Increased\n sob with increased level of activity. O2 at 2l/m nc and o2 sats> 975.\n lung sounds diminished to r lung and clear to lul with crackles at the\n l base.\n Action:\n Resp status monitored closely. pt given additional bolus of 500cc\ns ns\n after having receivied 2 liters in the ed. Hemodynamics followed\n closely as well. Pt had ultrasound of lower extremities to r/o dvt.\n Titrating heparin gtt as per weight based protocol\n Response:\n Pt\ns hr now in the 80\ns afib and sbp 88. pt napping\n Plan:\n Pt scheduled for repeat labs at 2100 and adjust heparin gtt\n accordingly. Pt to receive inhaler/nebs as ordered. Follow fever curve\n and administer tylenol as needed. Continue to assess pt\ns resp status\n and hemodynamics and bolus with additional ivf.antibiotic therapy as\n ordered.obtain abg if pt develops increased work of breathing or\n appears to be tiring oit.\n" }, { "category": "Nursing", "chartdate": "2141-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376988, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis, mssa\n pneumonia, afib, at, copd, chf with ef of 55%, osteoarthritis, pad,\n htn, migraine ha, chronic eosinophilic lung disease and hypoalbenemia.\n She presented to ed from nursing home with c/o fever, cough,\n recent infection and pleuritic r sided rib pain. Ct c/w extensive r pe,\n rll opacification concerning for pulm infection. Pt\ns usual bp runs\n 90-115. in ed temp=103 and sbp 80\ns. pt given Vancomycin, Cefepime and\n Tylenol. Bolused with 1 liter ns and given bolus of 4900 units heparin\n iv and gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on heparin gtt. BBS diminished t/o, and pt c/o frequent\n cough; however, denies SOB, reports cough has been unchanged over past\n several years, remains free of s/s distress. SpO2 98-100% on\n supplemental O2 2L via NC.\n Action:\n Monitoring respiratory status closely. PTT therapeutic at noon. Repeat\n PTT at 1800. Pt began heparin to coumadin therapy\n given coumadin 3mg\n PO at 1600 as ordered. Pt/family teaching re: coumadin initiated. Pt\n teaching handout provided.\n Response:\n Respiratory status stable. SpO2 remains 98-100% on 2L via NC. BBS\n diminished t/o. Pt continues w/ cough; however, denies changes in\n cough, denies SOB and remains free of diaphoresis or distress. Pt has\n continued to deny pain t/o shift. Cardiac enzymes have been negative\n times three sets.\n Plan:\n Continue to monitor respiratory status closely. Continue heparin to\n coumadin therapy. Monitor PTT q6hr. Monitor INR daily. Reinforce\n pt/family teaching re: coumadin therapy.\n Hypotension (not Shock)\n Assessment:\n Baseline SBP 90\ns. SBP has remained 80\ns to 90\ns w/ UOP borderline. Pt\n remains A+OX3, denies dizziness. Remains free of diaphoresis or\n distress.\n Action:\n Monitoring hemodynamic status closely. Pt given NS 500ml IVF bolus X 1\n LR 500ml IVF bolus X 1. UOP increases s/p IVF bolus. Urine specimen\n sent for U/A and urine lytes as ordered. PO fluids encouraged.\n Response:\n UOP >30ml/hr w/ IVF as above. w/ SBP 90\ns to low 100\ns (see flowsheet).\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for IVF\n if UOP <30ml/hr.\n" }, { "category": "Physician ", "chartdate": "2141-07-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377237, "text": "TITLE:\n Chief Complaint: Pulmonary Embolism\n 24 Hour Events:\n - Patient developed fever to 100.9, increased SOB, increased O2\n requirement, tachycardia and increased anxiety. CXR revealed R\n basilar opacification concerning for infarction from large PE. UA with\n few bacteria and WBC, trace leuk so patient started on macrobid (from\n previous urine sensitivities). Blood and urine cultures pending. Temp\n resolved and O2 requirement back down to 2L.\n - Patient received 20 mg IV lasix for increased SOB and +5 L fluid\n status for length of stay, made good urine with 800 cc output in 6\n hours. Systolic pressure transiently dropped to 76/41 but responded to\n 250 cc fluid bolus with SBP in patient\ns usual range of high-80\ns to\n mid 110\ns for remainder of 24 hours.\n SPUTUM CULTURE - At 01:06 PM\n BLOOD CULTURED - At 04:00 PM\n BLOOD CULTURED - At 04:36 PM\n URINE CULTURE - At 04:36 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:35 PM\n Enoxaparin (Lovenox) - 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 07:13 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: 37.1\nC (98.8\n HR: 93 (87 - 125) bpm\n BP: 103/53(65) {76/40(49) - 124/101(106)} mmHg\n RR: 25 (19 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,018 mL\n 102 mL\n PO:\n 430 mL\n 30 mL\n TF:\n IVF:\n 1,588 mL\n 72 mL\n Blood products:\n Total out:\n 1,585 mL\n 265 mL\n Urine:\n 1,585 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 433 mL\n -163 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortably, not coughing\n HEENT: NCAT, dry MM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds, scattered end-expiratory wheezes\n Abd: + Bowel sounds, minimally distended, non-tender\n Ext: Warm and well-perfused, no edema, no calf tenderness\n Neuro: Responds appropriately to questions, non-focal exam\n Labs / Radiology\n 320 K/uL\n 7.6 g/dL\n 84 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 111 mEq/L\n 141 mEq/L\n 23.5 %\n 7.4 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n 03:55 PM\n 05:17 AM\n WBC\n 10.6\n 8.3\n 7.4\n Hct\n 24.7\n 25.0\n 23.5\n Plt\n \n Cr\n 0.8\n 0.6\n 0.7\n 0.5\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n 84\n Other labs: PT / PTT / INR:19.4/63.0/1.8, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient currently on coumadin 3mg and lovenox with with subsequent\n INR at 1.8. Has been hemodynamically stable.\n - continue lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: Patient spiked a fever to Tmax 100.9. UA revealed few\n bacteria, trace leuk and 9 WBC. She was started on Macrobid (per\n sensitivity of previous UA). Blood and urine culture with no growth to\n date.\n - continue macrobid\n - d/c foley\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been hemodynamically stable.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - monitor on tele\nOLIGURIA: Patient had abundant UOP with lasix dose yesterday.\n - allow pt to auto-diurese\n - monitor I\ns and O\n HYPOKALEMIA: K is again slightly low today at 3.4. Patient\n daughter reports that she takes her own K supplementation at home; if\n her daughter brings this in she can take this form of PO K instead.\n - check pm K\nNON-GAP ACIDOSIS: Likely due to hydration with large volumes of NS.\n Has improved with changing fluids to LR.\n - continue LR for fluids\n - check lytes daily\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue lovenox \n ANEMIA: Hct slightly decreased today from paient\ns baseline hct in\n mid-to-high 20\n - check hct daily\n - transfuse for hct< 21\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 likely due to large PE.\n - wean O2 as tolerated\n - continue home COPD meds\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient appears\n euvolemic.\n - continue home meds\n H/O Atrial fibrillation: Patient has been in sinus since admission to\n \n - continue to monitor on tele\n ICU Care\n Nutrition: Heart healthy diet\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: Callout to medical floor today\n 16:10\n" }, { "category": "Nursing", "chartdate": "2141-07-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 377224, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, Currently afebrile. Tmax 98.7 oral . TEE one ~ showed L\n and R ventricles to be largely unchanged from pt\ns previous echo. PE\n likely due to prolonged immobilization with inadequate\n anticoagulation. Was on heparin gtt until 12 noon. currently on\n Lovenox 60 mg sc q 12 hrs, and Coumadin 3 mg po daily. LS with rhonchi\n , diminished at bases. Spo2 above 95% on 2LNC. Appears slightly\n tachypneic on exertion although denies any discomfort.\n Occasional productive cough , using yanker suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin.\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. Medicate with prn\n guafenasine with codein and ativan as needed.\n Hypotension (not Shock)\n Assessment:\n HR 90-100 . (per OMR notes\n pt has systolic bp\ns between high-80\ns to\n low 110\ns) BP trending up to 90-100 systolic when aroused. DP/PT\n doppler,U/O around 30-40cc/hr\n Action:\n K+ repleted\n Response:\n Haemodinamically remains stable.\n Plan:\n Continue to monitor hemodynamic status closely.\n" }, { "category": "Nursing", "chartdate": "2141-07-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376846, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis,mssa\n pneumonia, afib,at, copd,chf with ef of 555,osteoarthritis, pad, htn,\n migraine ha, chronic eosinophilic lung disease and hypoalbenemia. She\n presented to ed with c/o fever, cough, recent infection and\n pleuritic r sided rib pain. Ct c/w extensive r pe, rll opacification\n concerning for pulm infection. Pt\ns usual bp runs 90-115. in ed\n temp=103 and sbp 80\ns. pt given Vancomycin,cefepime and Tylenol.\n Bolused with 1 liter ns and given\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 377103, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging. LENI\ns ~ bilateral DVT\ns. CV\n echo done . EF 55%, mild-mod MR, tricuspid valve leaflets\n midly\n thickened.\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt on Heparin gtt @ 850 units/hr. d\ncd at 12 noon, Enoxaparin sodium\n 60 mg sc q 12 hours started at 1 pm. Pt also remains on Coumadin 3 mg\n po qd. Feet warm and dry, bilateral DP/PT pulses by doppler.\n Action:\n Heparin gtt d\ncd, pt started on Enoxaparin sc\n Response:\n Plan:\n Pt allowed OOB to chair,\n Hypotension (not Shock)\n Assessment:\n Pt maintaining SBP 95-115 and DBP above 50. UO 30 cc/hr. foley d\ncd @\n 2 pm. K~3.2 ~ pt received 40 meq KCL in 500 cc NS ~ infused.\n Action:\n Response:\n Urine output > 30 cc/hr.\n Plan:\n Pt to void by 10 pm. Monitor hemodynamic status closely.\n GI: fair appetite. Pt on regular, low NA/hrt healthy diet.\n" }, { "category": "Physician ", "chartdate": "2141-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377105, "text": "TITLE:\n Chief Complaint: Pleuritic right chest pain\n 24 Hour Events:\n - patient started on coumadin\n - briefly decreased (although unclear whether this was due to\n accidental foley removal), responded appropriately to 500 ml LR\n bolus with 60-70 cc\ns per hour this am\n - patient briefly developed non-gap acidosis with bicarb of 19,\n resolved with substitution of LR for NS for fluid boluses\n S: The patient is feeling well. Her chest pain has entirely resolved.\n She continues to have dry-mouth as well as her baseline amount of cough\n and shortness or breath. She has not had N/V diarrhea. No pain or\n swelling in her legs.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Heparin Sodium - 850 units/hour\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 07:16 AM\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: 36.4\nC (97.6\n HR: 80 (73 - 94) bpm\n BP: 99/55(67) {82/37(35) - 125/73(89)} mmHg\n RR: 18 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,315 mL\n 690 mL\n PO:\n 270 mL\n 60 mL\n TF:\n IVF:\n 2,045 mL\n 630 mL\n Blood products:\n Total out:\n 700 mL\n 250 mL\n Urine:\n 700 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,615 mL\n 440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortable\n HEENT: dry MMM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds throughout, lungs otherwise clear\n Abd: Soft, non-tender, +bowel sounds\n Ext: Warm and well-perfused, no edema or tenderness\n Neuro: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 293 K/uL\n 8.1 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 143 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n WBC\n 10.6\n 8.3\n Hct\n 24.7\n 25.0\n Plt\n 269\n 293\n Cr\n 0.8\n 0.6\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n Other labs: PT / PTT / INR:15.3/56.2/1.3, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.3 mg/dL, Mg++:2.0\n mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - transition from heparin drip to lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - will d/c abx today given her excellent clinical response to treatment\n of PE and clinical appearance not consistent with bacterial pneumonia\n - obtain sputum sample for culture in the event that patient spikes a\n fever\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been at at her usual BP (per outpatient OMR\n notes) of systolics between high-80\ns to low 110\n - continue fluid bolus to goal SBP >90, >30 cc/hr\nOLIGURIA: It is unclear whether the low recorded overnight was\n truly oliguria or due to the foley being accidentally removed;\n regardless her has been satisfactory since this receiving a 500 cc\n LR bolus. Creatinine of 0.6 suggests good renal function\n -d/c foley, encourage PO intake\n - monitor I\ns and O\nHYPONATREMIA: Patient with Na at nadir value of 133 (down from 138) at\n 4am on , likely dilutional given substantial amount of NS she\n received since admission. Has improved overnight with decreasing\n frequency of fluid boluses.\n - check lytes daily\n HYPOKALEMIA: Patient has refused PO K repletion, therefore will\n continue to slowly infuse IV K so as to avoid pain at infusion site.\n Patient\ns daughter reports that she takes her own K supplementation at\n home; if her daughter brings this in she can take this form of PO K\n instead.\n - check pm K\nNON-GAP ACIDOSIS: Likely due to hydration with large volumes of NS.\n Has improved with changing fluids to LR.\n - continue LR for fluids\n - check lytes daily\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - switch heparin drip to lovenox \n ANEMIA: Stable at patient\ns baseline Hct in mid-to-high 20\n - check Hct daily\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 likely due to large PE.\n - wean O2 as tolerated\n - continue home COPD meds\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x3. Echo yesterday showed\n ventricular size and function largely unchanged from previous echo.\n - continue home meds\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: Low-sodium diet\n Glycemic Control: Patient has been euglycemic, continue monitoring\n with daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: Likely call out to medical floor later today\n 13:28\n" }, { "category": "Physician ", "chartdate": "2141-07-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377200, "text": "TITLE:\n Chief Complaint: Pulmonary Embolism\n 24 Hour Events:\n - Patient developed fever to 100.9, increased SOB, increased O2\n requirement, tachycardia and increased anxiety. CXR revealed R\n basilar opacification concerning for infarction from large PE. UA with\n few bacteria and WBC, trace leuk so patient started on macrobid (from\n previous urine sensitivities). Blood and urine cultures pending. Temp\n resolved and O2 requirement back down to 2L.\n - Patient received 20 mg IV lasix for increased SOB and +5 L fluid\n status for length of stay, made good urine with 800 cc output in 6\n hours. Systolic pressure transiently dropped to 76/41 but responded to\n 250 cc fluid bolus with SBP in patient\ns usual range of high-80\ns to\n mid 110\ns for remainder of 24 hours.\n SPUTUM CULTURE - At 01:06 PM\n BLOOD CULTURED - At 04:00 PM\n BLOOD CULTURED - At 04:36 PM\n URINE CULTURE - At 04:36 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:35 PM\n Enoxaparin (Lovenox) - 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 07:13 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: 37.1\nC (98.8\n HR: 93 (87 - 125) bpm\n BP: 103/53(65) {76/40(49) - 124/101(106)} mmHg\n RR: 25 (19 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,018 mL\n 102 mL\n PO:\n 430 mL\n 30 mL\n TF:\n IVF:\n 1,588 mL\n 72 mL\n Blood products:\n Total out:\n 1,585 mL\n 265 mL\n Urine:\n 1,585 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 433 mL\n -163 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortably, not coughing\n HEENT: NCAT, dry MM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds, scattered end-expiratory wheezes\n Abd: + Bowel sounds, minimally distended, non-tender\n Ext: Warm and well-perfused, no edema, no calf tenderness\n Neuro: Responds appropriately to questions, non-focal exam\n Labs / Radiology\n 320 K/uL\n 7.6 g/dL\n 84 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 111 mEq/L\n 141 mEq/L\n 23.5 %\n 7.4 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n 03:55 PM\n 05:17 AM\n WBC\n 10.6\n 8.3\n 7.4\n Hct\n 24.7\n 25.0\n 23.5\n Plt\n \n Cr\n 0.8\n 0.6\n 0.7\n 0.5\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n 84\n Other labs: PT / PTT / INR:19.4/63.0/1.8, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 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": "2141-07-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377201, "text": "TITLE:\n Chief Complaint: Pulmonary Embolism\n 24 Hour Events:\n - Patient developed fever to 100.9, increased SOB, increased O2\n requirement, tachycardia and increased anxiety. CXR revealed R\n basilar opacification concerning for infarction from large PE. UA with\n few bacteria and WBC, trace leuk so patient started on macrobid (from\n previous urine sensitivities). Blood and urine cultures pending. Temp\n resolved and O2 requirement back down to 2L.\n - Patient received 20 mg IV lasix for increased SOB and +5 L fluid\n status for length of stay, made good urine with 800 cc output in 6\n hours. Systolic pressure transiently dropped to 76/41 but responded to\n 250 cc fluid bolus with SBP in patient\ns usual range of high-80\ns to\n mid 110\ns for remainder of 24 hours.\n SPUTUM CULTURE - At 01:06 PM\n BLOOD CULTURED - At 04:00 PM\n BLOOD CULTURED - At 04:36 PM\n URINE CULTURE - At 04:36 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:35 PM\n Enoxaparin (Lovenox) - 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 07:13 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: 37.1\nC (98.8\n HR: 93 (87 - 125) bpm\n BP: 103/53(65) {76/40(49) - 124/101(106)} mmHg\n RR: 25 (19 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,018 mL\n 102 mL\n PO:\n 430 mL\n 30 mL\n TF:\n IVF:\n 1,588 mL\n 72 mL\n Blood products:\n Total out:\n 1,585 mL\n 265 mL\n Urine:\n 1,585 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 433 mL\n -163 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortably, not coughing\n HEENT: NCAT, dry MM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds, scattered end-expiratory wheezes\n Abd: + Bowel sounds, minimally distended, non-tender\n Ext: Warm and well-perfused, no edema, no calf tenderness\n Neuro: Responds appropriately to questions, non-focal exam\n Labs / Radiology\n 320 K/uL\n 7.6 g/dL\n 84 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 111 mEq/L\n 141 mEq/L\n 23.5 %\n 7.4 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n 03:55 PM\n 05:17 AM\n WBC\n 10.6\n 8.3\n 7.4\n Hct\n 24.7\n 25.0\n 23.5\n Plt\n \n Cr\n 0.8\n 0.6\n 0.7\n 0.5\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n 84\n Other labs: PT / PTT / INR:19.4/63.0/1.8, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - transition from heparin drip to lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - will d/c abx today given her excellent clinical response to treatment\n of PE and clinical appearance not consistent with bacterial pneumonia\n - obtain sputum sample for culture in the event that patient spikes a\n fever\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been at at her usual BP (per outpatient OMR\n notes) of systolics between high-80\ns to low 110\n - continue fluid bolus to goal SBP >90, >30 cc/hr\nOLIGURIA: It is unclear whether the low recorded overnight was\n truly oliguria or due to the foley being accidentally removed;\n regardless her has been satisfactory since this receiving a 500 cc\n LR bolus. Creatinine of 0.6 suggests good renal function\n -d/c foley, encourage PO intake\n - monitor I\ns and O\nHYPONATREMIA: Patient with Na at nadir value of 133 (down from 138) at\n 4am on , likely dilutional given substantial amount of NS she\n received since admission. Has improved overnight with decreasing\n frequency of fluid boluses.\n - check lytes daily\n HYPOKALEMIA: Patient has refused PO K repletion, therefore will\n continue to slowly infuse IV K so as to avoid pain at infusion site.\n Patient\ns daughter reports that she takes her own K supplementation at\n home; if her daughter brings this in she can take this form of PO K\n instead.\n - check pm K\nNON-GAP ACIDOSIS: Likely due to hydration with large volumes of NS.\n Has improved with changing fluids to LR.\n - continue LR for fluids\n - check lytes daily\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - switch heparin drip to lovenox \n ANEMIA: Stable at patient\ns baseline Hct in mid-to-high 20\n - check Hct daily\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 likely due to large PE.\n - wean O2 as tolerated\n - continue home COPD meds\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x3. Echo yesterday showed\n ventricular size and function largely unchanged from previous echo.\n - continue home meds\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 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": "2141-07-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377178, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, sleepy this shift but easily arousable. Febrile previous\n shift, was pan cultured. Currently afebrile. Tmax 98.7 oral . TEE one\n ~ showed L and R ventricles to be largely unchanged from pt\n previous echo. PE likely due to prolonged immobilization with\n inadequate anticoagulation. Was on heparin gtt until 12 noon\n yesterday, d\ncd . currently on Lovenox 60 mg sc q 12 hrs, and Coumadin\n 3 mg po daily. LS with rhonchi , diminished at bases. Spo2 above 95%\n on 2LNC. Appears slightly tachypneic on exertion although denies any\n discomfort.\n Occasional productive cough , using yankar suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin. X1 dose of levalbuterol given this shift\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. ?call out to 5S\n tomorrow. Medicate with prn guafenasine with codein and ativan as\n needed.\n Hypotension (not Shock)\n Assessment:\n At start of shift pt sleeping, BP in mid 70\ns systolic , HR 90-100 .\n (per OMR notes\n pt has systolic bp\ns between high-80\ns to low 110\n BP trending up to 90-100 systolic when aroused. DP/PT doppler . Pt had\n received 20 mg IV lasix yesterday with good response and K+\n repletion.. U/O around 30-40cc/hr\n Action:\n This shift pt had banana ( for K+) ( secondary to refusal to take po\n K+. Team aware.\n Response:\n Good response to lasix\n Plan:\n Continue to monitor hemodynamic status closely. follow I+O\n closely. ? call out to floor today if hemodynamically stable. Follow\n up with a.m labs ( sent at 0530hrs)\n" }, { "category": "Nursing", "chartdate": "2141-07-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377191, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, sleepy this shift but easily arousable. Febrile previous\n shift, was pan cultured. Currently afebrile. Tmax 98.7 oral . TEE one\n ~ showed L and R ventricles to be largely unchanged from pt\n previous echo. PE likely due to prolonged immobilization with\n inadequate anticoagulation. Was on heparin gtt until 12 noon\n yesterday, d\ncd . currently on Lovenox 60 mg sc q 12 hrs, and Coumadin\n 3 mg po daily. LS with rhonchi , diminished at bases. Spo2 above 95%\n on 2LNC. Appears slightly tachypneic on exertion although denies any\n discomfort.\n Occasional productive cough , using yankar suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin. X1 dose of levalbuterol given this shift\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. ?call out to 5S\n tomorrow. Medicate with prn guafenasine with codein and ativan as\n needed.\n Hypotension (not Shock)\n Assessment:\n At start of shift pt sleeping, BP in mid 70\ns systolic , HR 90-100 .\n (per OMR notes\n pt has systolic bp\ns between high-80\ns to low 110\n BP trending up to 90-100 systolic when aroused. DP/PT doppler . Pt had\n received 20 mg IV lasix yesterday with good response and K+\n repletion.. U/O around 30-40cc/hr\n Action:\n This shift pt had banana ( for K+) ( secondary to refusal to take po\n K+. Team aware.\n Response:\n Good response to lasix\n Plan:\n Continue to monitor hemodynamic status closely. follow I+O\n closely. ? call out to floor today if hemodynamically stable. Follow\n up with a.m labs ( sent at 0530hrs)\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377060, "text": "Nursing Progress Note\n Pt is an 81 yo female w/ PMHx of cdiff colitis, MSSA pna, afib and\n atrial tachycardia, COPD, CHF w/ an EF on 55%, osteoarthritis, PAD,\n HTN, migraine HA, chronic eosinophilic lung disease and\n hypoalbuminemia. She presented to ED from nursing home w/ c/o of\n fever, cough, recent infx, and pleuritic right sided rib pain. CT\n consistent with extensive right PE, RLL opacification concerning for\n pulmonary infx. Pt\ns baseline SBP runs 90-115. In ED temp was 103 and\n SBP in 80s. Pt given vancomycin, cefepime, and Tylenol. Bolused w/ 1\n L NS and given bolus of 4900 U heparin IV and gtt initiated and running\n at 1100 units/hr. After Tylenol repeat temp at 100.5. Pt transferred\n to for further management. Upon arrival, pt afebrile but HR in\n 120s and SBP 85. Pt bolused w/ additional 500 cc\ns NS.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received patient on heparin gtt at 750units/hr w/PTT at 60.7 and\n coumadin 3mg daily. No signs of bleeding noted. BBS diminished\n throughout w/ no adventitious sounds noted. Pt has persistent, dry\n cough which pt explains is at baseline. Pt on 4L O2 NC with sats above\n 98%. Remains free from distress at rest, but gets SOB w/ lots of\n activity. Pt denied pain throughout shift. Pt\ns PTT decreased to 56.2\n and INR at 1.3 at 3:00\n Action:\n Increased pt\ns heparin gtt to 850 U/hr per sliding scale but did not\n hep bolus per Dr. . Monitoring pt\ns respiratory status\n closely. Kept head of bed elevated and O2 at 4L/min. total of\n 15 mL robitussin throughout the night.\n Response:\n Pt maintained stable respiratory status and O2 saturation. Cough\n persisted throughout shift w/ moderate relief from Robitussin.\n Plan:\n Continue to monitor respiratory status. Continue w/ heparin per\n sliding scale and once daily coumadin therapy. Monitor both PTT and\n INR. Recheck PTT at 10am.\n Hypotension (not Shock)\n Assessment:\n Pt maintained SBP between 90 and 115 and DBP above 50. Pt\ns urinary\n output maintained around 30 ml/hr. Foley was displaced after 1:00 w/\n large incontinence noted and replaced at 3:00. Pt\ns HR 80-95. Pt\n remained A and O X 3, denied dizziness, and remained free of\n diaphoresis and distress\n Action:\n Monitored pt\ns hemodynamic status closely. Pt given 500 mL IVF bolus X\n 1 at 1:45 in response to lack of urine output which was actually\n secondary to foley displacement.\n Response:\n UOP > 30 ml/hr and SBP above 90.\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for\n IVF if UOP < 30 ml/hr.\n *Pt remained afebrile w/ temps < 98\n *Pt\ns K at 3.2 at 3:00 down from 3.4. Pt denied PO forms of K, \n MD 40meq/500 starting at 6:00.\n" }, { "category": "General", "chartdate": "2141-07-20 00:00:00.000", "description": "Generic Note", "row_id": 377093, "text": "TITLE: Critical Care\n Present for the key portions of the residnet\ns histroy and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds. Still coughing.\n 97.5 91 116/60\n Alert comfortable\n Chest\n prolonged exhalation few crackles R\n Abd soft\n Creat 0.6\n UO has improved with placement of new Foley and creat is at baseline.\n Continuing heparin while starting on coumadin. We will stop abx as\n initial fever, however high, seems likely to be due to VTE. Will d/c\n Foley. Feeling close to baseline.\n Time spent 30 min\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 377097, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fev--ers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n" }, { "category": "Physician ", "chartdate": "2141-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377098, "text": "TITLE:\n Chief Complaint: Pleuritic right chest pain\n 24 Hour Events:\n - patient started on coumadin\n - UOP briefly decreased (although unclear whether this was due to\n accidental foley removal), UOP responded appropriately to 500 ml LR\n bolus with UOP 60-70 cc\ns per hour this am\n - patient briefly developed non-gage acidosis with bicarb of 19,\n resolved with substitution of LR for NS for fluid boluses\n S: The patient is feeling well. Her chest pain has entirely resolved.\n She continues to have dry-mouth as well as her baseline amount of cough\n and shortness or breath. She has not had N/V diarrhea. No pain or\n swelling in her legs.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Heparin Sodium - 850 units/hour\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 07:16 AM\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: 36.4\nC (97.6\n HR: 80 (73 - 94) bpm\n BP: 99/55(67) {82/37(35) - 125/73(89)} mmHg\n RR: 18 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,315 mL\n 690 mL\n PO:\n 270 mL\n 60 mL\n TF:\n IVF:\n 2,045 mL\n 630 mL\n Blood products:\n Total out:\n 700 mL\n 250 mL\n Urine:\n 700 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,615 mL\n 440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortable\n HEENT: dry MMM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds throughout, lungs otherwise clear\n Abd: Soft, non-tender, +bowel sounds\n Ext: Warm and well-perfused, no edema or tenderness\n Neuro: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 293 K/uL\n 8.1 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.2 mEq/L\n 9 mg/dL\n 111 mEq/L\n 143 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n WBC\n 10.6\n 8.3\n Hct\n 24.7\n 25.0\n Plt\n 269\n 293\n Cr\n 0.8\n 0.6\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n Other labs: PT / PTT / INR:15.3/56.2/1.3, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.3 mg/dL, Mg++:2.0\n mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient started on coumadin 3mg with subsequent INR at 1.3. Has been\n hemodynamically stable.\n - transition from heparin drip to lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: After initial Tmax of 103.4 in ED, the patient has now been\n afebrile for over 24 hours.\n - will d/c abx today given her excellent clinical response to treatment\n of PE\n - obtain sputum sample for culture to help narrow antibiotic coverage\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been at at her usual BP (per outpatient OMR\n notes) of systolics between high-80\ns to low 110\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\nHYPONATREMIA: Patient with Na at nadir value of 133 (down from 138) at\n 4am on , likely dilutional given substantial amount of NS she\n received since admission. Fluids switched to LR\n HYPOKALEMIA:\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: Low-sodium diet\n Glycemic Control: Patient has been euglycemic, continue monitoring\n with daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: Likely call out to medical floor later today\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376920, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. LENI\ns performed yesterday show clot in\n both lower extremities. Has been hemodynamically stable without need\n for tPA or surgical intervention.\n - continue heparin drip\n - bedside echo today to evaluate RV function\n - continue close monitoring of hemodynamic status\n - will likely need long-term anticoagulation with coumadin\n - consider IVC filter given large existing PE and significant clot\n burden in lower extremities\n FEVER: The patient\ns high Tmax (103.4) is unlikely to be due to PE\n alone. RLL infiltrate on CXR suggests possible infectious process\n which is also supported by patient\ns down-trending temp curve and\n stable WBC while on antibiotics for hospital-acquired pneumonia.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - continue mini-stress dose steroids for possible component of adrenal\n insufficiency in this patient on long term steroid therapy\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n - consider IVC filter\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n Hypocalcemia:\n ICU Care\n Nutrition: NPO since midnight for possible procedure today\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 376892, "text": "Briefly this is a 81 yo female with pmh of cdiff colitis, mssa\n pneumonia, afib, at, copd, chf with ef of 55%, osteoarthritis, pad,\n htn, migraine ha, chronic eosinophilic lung disease and hypoalbenemia.\n She presented to ed from nursing home with c/o fever, cough,\n recent infection and pleuritic r sided rib pain. Ct c/w extensive r pe,\n rll opacification concerning for pulm infection. Pt\ns usual bp runs\n 90-115. in ed temp=103 and sbp 80\ns. pt given Vancomycin, Cefepime and\n Tylenol. Bolused with 1 liter ns and given bolus of 4900 units heparin\n iv and gtt initated and running at 1100units/hr. after Tylenol repeat\n temp=100.5. pt transferred to for further management. Upon\n arrival pt afebrile but hr in 120\ns afib and sbp 85. pt bolused with\n additional 500cc\ns ns\n Chest Pain: pt admitted with report of right sided chest pain, now\n resolved, trending CE, first two sets flat, third pending with am labs,\n f/u CE, continue to monitor for CP\n Afib: pt in Afib with a rate of 130s on admission from EW, found to be\n in NSR at change of shift, remained in SR throughout the shift, pt with\n hx of Afib has never been anticoagulated in that past\n Pulmonary Embolism (PE), Acute\n Assessment:\n CT yesterday with extensive right PE, pt on heparin gtt, LENIs\n yesterday day with bilat DVTs\n Action:\n Q6hr ptt, titrating heparin infusion per protocol, pt NPO except meds\n after midnight\n Response:\n Ptt supratherapeutic with evening draw, am labs pending\n Plan:\n Continue hep gtt, ?IVC filter placement today plan per resident though\n orders pending, continue q6hr ptt next to be drawn at 1000\n Hypotension (not Shock)\n Assessment:\n BP: 83-118/47-57, baseline BP 90-115 systolic\n Action:\n Given 2 500 cc NS boluses\n Response:\n Responding to fluid boluses, borderline u/o\n Plan:\n Continue to monitor, continue to treat with fluid boluses\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt maintaining sats of 2 L NC, breath sounds dim throughout, persistent\n cough chronic per patient report, productive at times though largely\n dry\n Action:\n Treating cough with guiafenisin/codiene, given trazadone\n Response:\n Pt with no relief to cough, awake most of night, O2 requirement\n increased around 0400 to 4L NC pt denies increased SOB\n Plan:\n Continue to monitor, titrate supplemental O2 as tolerated\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376912, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n on hep gtt\n HYPOTENSION (NOT SHOCK)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n on vancomycin, ciprofloxacin\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n .H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC\n ICU Care\n Nutrition: NPO since midnight for possible procedure\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377024, "text": "Nursing Progress Note\n Pt is an 81 yo female w/ PMHx of cdiff colitis, MSSA pna, afib and\n atrial tachycardia, COPD, CHF w/ an EF on 55%, osteoarthritis, PAD,\n HTN, migraine HA, chronic eosinophilic lung disease and\n hypoalbuminemia. She presented to ED from nursing home w/ c/o of\n fever, cough, recent infx, and pleuritic right sided rib pain. CT\n consistent with extensive right PE, RLL opacification concerning for\n pulmonary infx. Pt\ns baseline SBP runs 90-115. In ED temp was 103 and\n SBP in 80s. Pt given vancomycin, cefepime, and Tylenol. Bolused w/ 1\n L NS and given bolus of 4900 U heparin IV and gtt initiated and running\n at 1100 units/hr. After Tylenol repeat temp at 100.5. Pt transferred\n to for further management. Upon arrival, pt afebrile but HR in\n 120s and SBP 85. Pt bolused w/ additional 500 cc\ns NS.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377030, "text": "Nursing Progress Note\n Pt is an 81 yo female w/ PMHx of cdiff colitis, MSSA pna, afib and\n atrial tachycardia, COPD, CHF w/ an EF on 55%, osteoarthritis, PAD,\n HTN, migraine HA, chronic eosinophilic lung disease and\n hypoalbuminemia. She presented to ED from nursing home w/ c/o of\n fever, cough, recent infx, and pleuritic right sided rib pain. CT\n consistent with extensive right PE, RLL opacification concerning for\n pulmonary infx. Pt\ns baseline SBP runs 90-115. In ED temp was 103 and\n SBP in 80s. Pt given vancomycin, cefepime, and Tylenol. Bolused w/ 1\n L NS and given bolus of 4900 U heparin IV and gtt initiated and running\n at 1100 units/hr. After Tylenol repeat temp at 100.5. Pt transferred\n to for further management. Upon arrival, pt afebrile but HR in\n 120s and SBP 85. Pt bolused w/ additional 500 cc\ns NS.\n Pulmonary Embolism (PE), Acute\n Assessment:\n PTT was 60 at 18:00 and in therapeutic range. Heparin gtt maintained\n at 750 U/hr. Pt also began 3 mg Coumadin at 1600. No signs of\n bleeding noted. BBS diminished throughout. Pt has persistent, dry\n cough which pt explains is her baseline. Pt on 4L O2 NC with sats\n above 98%. Remains free from distress at rest, but gets SOB w/ lots of\n activity. Pt denied pain throughout shift.\n Action:\n Monitoring pt\ns respiratory status closely. Kept head of bed elevated\n and O2 at 4L/min. Admin total of 15 mL robitussin throughout the\n night. Heparin continued at 750 U/hr. Labs drawn at 03:00 and waiting\n results.\n Response:\n Pt maintained stable respiratory status and O2 saturation. Cough\n persisted throughout shift w/ moderate relief from Robitussin.\n Plan:\n Continue to monitor respiratory status. Continue w/ heparin and\n coumadin therapy. Monitor both PTT and INR daily.\n Hypotension (not Shock)\n Assessment:\n Pt maintained SBP between 90 and 115 and DBP above 50. Pt\ns urinary\n output maintained around 30 ml/hr. Foley was displaced after 1:00 w/\n large incontinence noted and replaced at 3:00. Pt\ns HR 80-95. Pt\n remained A and O X 3, denied dizziness, and remained free of\n diaphoresis and distress. U/A and urine lytes still pending.\n Action:\n Monitored pt\ns hemodynamic status closely. Pt given 500 mL IVF bolus X\n 1 at 1:45 in response to lack of urine output which was actually\n secondary to foley displacement.\n Response:\n UOP > 30 ml/hr and SBP above 90.\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for\n IVF if UOP < 30 ml/hr.\n Pt remained afebrile w/ temps < 98. Pt\ns K at 3.4\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377161, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, sleepy this shift but easily arousable. Febrile previous\n shift, was pan cultured. Currently afebrile. Tmax . TEE one ~ showed\n L and R ventricles to be largely unchanged from pt\ns previous echo. PE\n likely due to prolonged immobilization with inadequate\n anticoagulation. Was on heparin gtt until 12 noon yesterday, d\ncd .\n currently on Lovenox 60 mg sc q 12 hrs, and Coumadin 3 mg po daily. LS\n with rhonchi , diminished at bases. Spo2 above 95% on 2LNC. Appears\n slightly tachypneic on exertion although denies any discomfort.\n Occasional productive cough , using yankar suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. ?call out to 5S\n tomorrow. Medicate with prn guafenasine with codein and ativan as\n needed.\n Hypotension (not Shock)\n Assessment:\n At start of shift pt sleeping, BP in mid 70\ns systolic , HR 90-100 .\n (per OMR notes\n pt has systolic bp\ns between high-80\ns to low 110\n BP trending up to 90-100 systolic when aroused. DP/PT doppler . Pt had\n received 20 mg IV lasix yesterday with good response and K+ repletion..\n Action:\n This shift pt had bananas ( for K+) ( secondary to refusal to take po\n K+\n Response:\n Good response to lasix\n Plan:\n Continue to monitor hemodynamic status closely. follow I+O\n closely. ? call out to floor today if hemodynamically stable.\n ID: antibx d\ncd on rounds.. WBC 8.3 afebrile then temp 100.9\n po, blood cultures x 2, urine and sputum cx\ns sent. 650 mg po\n Tylenol given at 1630\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377032, "text": "Nursing Progress Note\n Pt is an 81 yo female w/ PMHx of cdiff colitis, MSSA pna, afib and\n atrial tachycardia, COPD, CHF w/ an EF on 55%, osteoarthritis, PAD,\n HTN, migraine HA, chronic eosinophilic lung disease and\n hypoalbuminemia. She presented to ED from nursing home w/ c/o of\n fever, cough, recent infx, and pleuritic right sided rib pain. CT\n consistent with extensive right PE, RLL opacification concerning for\n pulmonary infx. Pt\ns baseline SBP runs 90-115. In ED temp was 103 and\n SBP in 80s. Pt given vancomycin, cefepime, and Tylenol. Bolused w/ 1\n L NS and given bolus of 4900 U heparin IV and gtt initiated and running\n at 1100 units/hr. After Tylenol repeat temp at 100.5. Pt transferred\n to for further management. Upon arrival, pt afebrile but HR in\n 120s and SBP 85. Pt bolused w/ additional 500 cc\ns NS.\n Pulmonary Embolism (PE), Acute\n Assessment:\n PTT was 60 at 18:00 and in therapeutic range. Heparin gtt maintained\n at 750 U/hr. Pt also began 3 mg Coumadin at 1600. No signs of\n bleeding noted. BBS diminished throughout. Pt has persistent, dry\n cough which pt explains is her baseline. Pt on 4L O2 NC with sats\n above 98%. Remains free from distress at rest, but gets SOB w/ lots of\n activity. Pt denied pain throughout shift.\n Action:\n Monitoring pt\ns respiratory status closely. Kept head of bed elevated\n and O2 at 4L/min. Admin total of 15 mL robitussin throughout the\n night. Heparin continued at 750 U/hr. Labs drawn at 03:00 and waiting\n results.\n Response:\n Pt maintained stable respiratory status and O2 saturation. Cough\n persisted throughout shift w/ moderate relief from Robitussin.\n Plan:\n Continue to monitor respiratory status. Continue w/ heparin and\n coumadin therapy. Monitor both PTT and INR daily.\n Hypotension (not Shock)\n Assessment:\n Pt maintained SBP between 90 and 115 and DBP above 50. Pt\ns urinary\n output maintained around 30 ml/hr. Foley was displaced after 1:00 w/\n large incontinence noted and replaced at 3:00. Pt\ns HR 80-95. Pt\n remained A and O X 3, denied dizziness, and remained free of\n diaphoresis and distress. U/A and urine lytes still pending.\n Action:\n Monitored pt\ns hemodynamic status closely. Pt given 500 mL IVF bolus X\n 1 at 1:45 in response to lack of urine output which was actually\n secondary to foley displacement.\n Response:\n UOP > 30 ml/hr and SBP above 90.\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for\n IVF if UOP < 30 ml/hr.\n Pt remained afebrile w/ temps < 98. Pt\ns K at 3.2 and given IV K. Hep\n gtt increased to 850 U/hr per PTT at 56.2 No bolus given per .\n" }, { "category": "Nursing", "chartdate": "2141-07-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 377248, "text": "81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging LENI\ns positive for DVT\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt A/O x 3, Currently afebrile. Tmax 98.7 oral . TEE one ~ showed L\n and R ventricles to be largely unchanged from pt\ns previous echo. PE\n likely due to prolonged immobilization with inadequate\n anticoagulation. Was on heparin gtt until 12 noon. currently on\n Lovenox 60 mg sc q 12 hrs, and Coumadin 3 mg po daily. LS with rhonchi\n , diminished at bases. Spo2 above 95% on 2LNC. Appears slightly\n tachypneic on exertion although denies any discomfort.\n Occasional productive cough , using yanker suction for tan\n secretions. Antibiotics d\ncd on rounds yesterday\n Action:\n On lovenox and coumadin.\n Response:\n SOB with activity\n Plan:\n Continue to monitor INR monitor resp status. Medicate with prn\n guafenasine with codein and ativan as needed.\n Hypotension (not Shock)\n Assessment:\n Afebrile HR 90-100 . BP 100 -120 . DP/PT doppler,U/O around\n 30-40cc/hr\n Action:\n K+ repleted,pt refused to take the prescribed dose had only 20 mEq,had\n banana with diet.\n Response:\n Haemodinamically remains stable.\n Plan:\n Continue to monitor hemodynamic status closely.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 62.4 kg\n Daily weight:\n Allergies/Reactions:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Precautions:\n PMH: COPD\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: migraine ha,hx cdiff colitis and mssa\n pneumonia,af.at, osteoarthritis, pad,chronic eosonophilic lung dx. and\n hypoalbunemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:61\n Temperature:\n 96\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 Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 230 mL\n 24h total out:\n 590 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:17 AM\n Potassium:\n 3.4 mEq/L\n 05:17 AM\n Chloride:\n 111 mEq/L\n 05:17 AM\n CO2:\n 22 mEq/L\n 05:17 AM\n BUN:\n 6 mg/dL\n 05:17 AM\n Creatinine:\n 0.5 mg/dL\n 05:17 AM\n Glucose:\n 84 mg/dL\n 05:17 AM\n Hematocrit:\n 23.5 %\n 05:17 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent with pt\n / Money:\n No money / none\n Cash / Credit cards sent home with:none\n Jewelry: none\n Transferred from: MICU/SICU 403\n Transferred to: 1179\n Date & time of Transfer: @ 1800\n" }, { "category": "Physician ", "chartdate": "2141-07-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 377259, "text": "TITLE:\n Chief Complaint: Pulmonary Embolism\n 24 Hour Events:\n - Patient developed fever to 100.9, increased SOB, increased O2\n requirement, tachycardia and increased anxiety. CXR revealed R\n basilar opacification concerning for infarction from large PE. UA with\n few bacteria and WBC, trace leuk so patient started on macrobid (from\n previous sensitivities). Blood and cultures pending. Temp\n resolved and O2 requirement back down to 2L.\n - Patient received 20 mg IV lasix for increased SOB and +5 L fluid\n status for length of stay, made good with 800 cc output in 6\n hours. Systolic pressure transiently dropped to 76/41 but responded to\n 250 cc fluid bolus with SBP in patient\ns usual range of high-80\ns to\n mid 110\ns for remainder of 24 hours.\n SPUTUM CULTURE - At 01:06 PM\n BLOOD CULTURED - At 04:00 PM\n BLOOD CULTURED - At 04:36 PM\n CULTURE - At 04:36 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:02 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:35 PM\n Enoxaparin (Lovenox) - 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 07:13 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: 37.1\nC (98.8\n HR: 93 (87 - 125) bpm\n BP: 103/53(65) {76/40(49) - 124/101(106)} mmHg\n RR: 25 (19 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,018 mL\n 102 mL\n PO:\n 430 mL\n 30 mL\n TF:\n IVF:\n 1,588 mL\n 72 mL\n Blood products:\n Total out:\n 1,585 mL\n 265 mL\n :\n 1,585 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 433 mL\n -163 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n Gen: Elderly woman in NAD, sleeping comfortably, not coughing\n HEENT: NCAT, dry MM, no JVD\n CV: RRR, no murmurs\n Lungs: Decreased breath sounds, scattered end-expiratory wheezes\n Abd: + Bowel sounds, minimally distended, non-tender\n Ext: Warm and well-perfused, no edema, no calf tenderness\n Neuro: Responds appropriately to questions, non-focal exam\n Labs / Radiology\n 320 K/uL\n 7.6 g/dL\n 84 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 6 mg/dL\n 111 mEq/L\n 141 mEq/L\n 23.5 %\n 7.4 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n 02:55 AM\n 03:55 PM\n 05:17 AM\n WBC\n 10.6\n 8.3\n 7.4\n Hct\n 24.7\n 25.0\n 23.5\n Plt\n \n Cr\n 0.8\n 0.6\n 0.7\n 0.5\n TropT\n 0.01\n <0.01\n Glucose\n 99\n 101\n 84\n Other labs: PT / PTT / INR:19.4/63.0/1.8, CK / CKMB /\n Troponin-T:31/3/<0.01, Differential-Neuts:77.2 %, Lymph:17.6 %,\n Mono:4.6 %, Eos:0.5 %, Lactic Acid:1.1 mmol/L, Ca++:7.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fevers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. TTE performed yesterday appears showed L\n and R ventricles to be largely unchanged from patient\ns previous echo.\n Patient currently on coumadin 3mg and lovenox with with subsequent\n INR at 1.8. Has been hemodynamically stable.\n - continue lovenox \n - will continue coumadin at 3 mg today and recheck INR; patient is\n hesitant to take coumadin long-term. Will need to discuss long term\n coumadin vs lovenox with her PCP ( ) and her pulmonoligist (\n )\n - continue close monitoring of hemodynamic status\n FEVER: Patient spiked a fever to Tmax 100.9. UA revealed few\n bacteria, trace leuk and 9 WBC. She was started on Macrobid (per\n sensitivity of previous UA). Blood and culture with no growth to\n date.\n - continue macrobid\n - d/c foley\n - f/u blood, cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Patient has been hemodynamically stable.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - monitor on tele\nOLIGURIA: Patient had abundant UOP with lasix dose yesterday.\n - allow pt to auto-diurese\n - monitor I\ns and O\n HYPOKALEMIA: K is again slightly low today at 3.4. Patient\n daughter reports that she takes her own K supplementation at home; if\n her daughter brings this in she can take this form of PO K instead.\n - check pm K\nNON-GAP ACIDOSIS: Likely due to hydration with large volumes of NS.\n Has improved with changing fluids to LR.\n - continue LR for fluids\n - check lytes daily\nHISTORY OF EOSINOPHILIC LUNG DISEASE: No evidence of exacerbation of\n disease at this time\n - continue home dose prednisone 5 mg daily\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue lovenox \n ANEMIA: Hct slightly decreased today from paient\ns baseline hct in\n mid-to-high 20\n - check hct daily\n - transfuse for hct< 21\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 likely due to large PE.\n - wean O2 as tolerated\n - continue home COPD meds\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient appears\n euvolemic.\n - continue home meds\n H/O Atrial fibrillation: Patient has been in sinus since admission to\n \n - continue to monitor on tele\n ICU Care\n Nutrition: Heart healthy diet\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Lovenox\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: Callout to medical floor today\n 16:10\n ------ Protected Section ------\n 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 morning\n rounds. Feeling better. BP remains somewhat labile with periods of\n relative hypotension but no change in MS output.\n 99.5 84 117/63\n Chest\n prolonged exhalation\n w/o edema\n Recovering from VTE. No evidence of active infection. Well\n anticoagulated. I think with AF she might be a candidate for lifelong\n anticoag\n Time spent 30 min\n ------ Protected Section Addendum Entered By: , MD\n on: 18:34 ------\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376955, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fev--ers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. LENI\ns performed yesterday show clot in\n both lower extremities. Has been hemodynamically stable without need\n for tPA or surgical intervention.\n - continue heparin drip\n - bedside echo today to evaluate RV function\n - continue close monitoring of hemodynamic status\n - will need long-term anticoagulation with coumadin, begin coumadin 3\n mg today and re-check INR\n FEVER: The patient\ns high Tmax (103.4) is unlikely to be due to PE\n alone. RLL infiltrate on CXR suggests possible infectious process\n which is also supported by patient\ns down-trending temp curve and\n stable WBC while on antibiotics for hospital-acquired pneumonia.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - has completed mini-stress dose steroids for possible component of\n adrenal insufficiency in this patient on long term steroid therapy,\n transition back to home dose of prednisone 5 mg daily\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: NPO since midnight for possible procedure today\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376956, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fev--ers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. LENI\ns performed yesterday show clot in\n both lower extremities. Has been hemodynamically stable without need\n for tPA or surgical intervention.\n - continue heparin drip\n - bedside echo today to evaluate RV function\n - continue close monitoring of hemodynamic status\n - will need long-term anticoagulation with coumadin, begin coumadin 3\n mg today and re-check INR\n FEVER: The patient\ns high Tmax (103.4) is unlikely to be due to PE\n alone. RLL infiltrate on CXR suggests possible infectious process\n which is also supported by patient\ns down-trending temp curve and\n stable WBC while on antibiotics for hospital-acquired pneumonia.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - has completed mini-stress dose steroids for possible component of\n adrenal insufficiency in this patient on long term steroid therapy,\n transition back to home dose of prednisone 5 mg daily\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: NPO since midnight for possible procedure today\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n 11:21\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376958, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fev--ers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. LENI\ns performed yesterday show clot in\n both lower extremities. Has been hemodynamically stable without need\n for tPA or surgical intervention.\n - continue heparin drip\n - bedside echo today to evaluate RV function\n - continue close monitoring of hemodynamic status\n - will need long-term anticoagulation with coumadin, begin coumadin 3\n mg today and re-check INR\n FEVER: The patient\ns high Tmax (103.4) is unlikely to be due to PE\n alone. RLL infiltrate on CXR suggests possible infectious process\n which is also supported by patient\ns down-trending temp curve and\n stable WBC while on antibiotics for hospital-acquired pneumonia.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - will check stool for c. diff if patient develops diarrhea given her\n recent history of c. diff colitis\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - has completed mini-stress dose steroids for possible component of\n adrenal insufficiency in this patient on long term steroid therapy,\n transition back to home dose of prednisone 5 mg daily\nOLIGURIA: The patient maintained an average UOP of 40 cc/hr in the\n first day of her hospitalization, however this am she had UOP of 10 cc\n from 9am to 10am. There is a likely a pre-renal component in this\n patient with hypovolemia as well as possible nephrotoxicity from the\n contrast she received during her CTA.\n - 500 fluid bolus now, then evaluate UOP over next 3 hours (goal >30\n cc/hr). If goal is not met, will check UA and urine lytes.\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n ANEMIA: Hct down to 7 points from admission to 24.7, however there is\n no evidence of bleeding, the patient was guiaic negative in the ED, and\n her baseline Hct in previous admission has been in the mid-to-high\n 20\ns. She also received 1.5 L fluid over the course of the day\n yesterday which may causing hemodilution.\n - check pm Hct\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n ICU Care\n Nutrition: NPO since midnight for possible procedure today\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n 11:21\n ------ Protected Section ------\n Pt seen and examinied. Agree with medical student note above.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:32 ------\n" }, { "category": "Physician ", "chartdate": "2141-07-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 376938, "text": "TITLE: MS4 Progress Note\n Chief Complaint: Pleuritic R chest pain\n 24 Hour Events:\n - Admitted.\n Subjective:\n The patient continues to have cough and dry mouth. She does not have\n increased SOB. Her chest pain has resolved. No N/V or diarrhea.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Flagyl (Oral) (Metronidazole)\n Wheezing;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Infusions:\n Heparin Sodium - 750 units/hour\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 06:44 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: 36.2\nC (97.2\n HR: 72 (70 - 128) bpm\n BP: 109/53(67) {83/42(47) - 118/57(69)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 3,568 mL\n 56 mL\n PO:\n TF:\n IVF:\n 1,568 mL\n 56 mL\n Blood products:\n Total out:\n 815 mL\n 245 mL\n Urine:\n 315 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,753 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG:\n Physical Examination\n Gen: Elderly woman in NAD, intermittently coughing, does not appear\n acutely ill\n HEENT: NCAT, PERRL, Dry MM, neck veins flat\n CV: RRR, nl S1 S2, no murmurs\n Lungs: Decreased breath sounds throughout, faint end-expiratory wheezes\n Abd: Soft, non-tender, bowel sounds present\n Ext: No edema or calf tenderness, warms and well-perfused, DP pulse\n palpable bilaterally\n Neurologic: Responds appropriately to questions, grossly non-focal\n Labs / Radiology\n 269 K/uL\n 7.9 g/dL\n 99 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 105 mEq/L\n 133 mEq/L\n 24.7 %\n 10.6 K/uL\n [image002.jpg]\n 08:16 PM\n 04:10 AM\n WBC\n 10.6\n Hct\n 24.7\n Plt\n 269\n Cr\n 0.8\n TropT\n 0.01\n <0.01\n Glucose\n 99\n Other labs: PT / PTT / INR:16.5/112.5/1.5, CK / CKMB /\n Troponin-T:31/3/<0.01, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 81F with h/o chronic eosinophilic lung disease, COPD, diastolic CHF,\n and recent admission for MSSA and pan-sensitive Pseudomonas PNA who\n presents with fev--ers, right sided pleuritic chest pain and found to\n have extensive R sided PE on imaging.\n PULMONARY EMBOLISM: Likely due to prolonged immobilization with\n inadequate anticoagulation. LENI\ns performed yesterday show clot in\n both lower extremities. Has been hemodynamically stable without need\n for tPA or surgical intervention.\n - continue heparin drip\n - bedside echo today to evaluate RV function\n - continue close monitoring of hemodynamic status\n - will likely need long-term anticoagulation with coumadin\n - consider IVC filter given large existing PE and significant clot\n burden in lower extremities\n FEVER: The patient\ns high Tmax (103.4) is unlikely to be due to PE\n alone. RLL infiltrate on CXR suggests possible infectious process\n which is also supported by patient\ns down-trending temp curve and\n stable WBC while on antibiotics for hospital-acquired pneumonia.\n - continue vancomycin, ciprofloxacin\n - obtain sputum sample for culture\n - f/u blood, urine cultures\n - continue to trend WBC and temp curve\n HYPOTENSION: Likely has both cardiogenic and septic components, with\n cardiogenic being dominant process given patient\ns excellent response\n to fluid bolus (suggests pre-load dependence). She has intermittently\n had systolic BP\ns in the 80\ns but has not required pressors with\n appropriate fluid bolus.\n - continue fluid bolus to goal SBP >90, UOP >30 cc/hr\n - continue antibiotics as above for possible septic component\n - continue mini-stress dose steroids for possible component of adrenal\n insufficiency in this patient on long term steroid therapy\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY: LENI\ns reveal\n significant clot burden ( R common fem extending into greater saphenous\n and profunda femorus, L peroneal)\n - continue heparin drip\n - consider IVC filter\n H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION: Patient appears at her baseline\n breathing status without increased SOB or cough, however is requiring\n supplemental O2 (increased from 2L to 4L o/n when patient briefly\n desaturated to 93%), likely due to large PE.\n - continue supplement O2 and wean as tolerated\n - continue home COPD meds\n - will use morphine for chest pain relief for it\ns additional property\n of relieving air hunger\n H/O HEART FAILURE (CHF), DIASTOLIC, CHRONIC: Patient currently\n appears euvolemic-to-dry, and is without cardiac symptoms. Minimal ST\n depressions seen on initial EKG (< 1mm in V4-V6) likely due to demand\n since cardiac enzymes have been negative x2.\n - echo today to evaluate ventricular function\n - f/u third set of cardiac enzymes\n - repeat EKG this am\n H/O Atrial fibrillation: Patient was initially in afib on arrival to\n in setting of fever, tachycardia and hypotension but has been in\n sinus rhythm since 7pm.\n - continue to monitor on tele\n Hypocalcemia:\n ICU Care\n Nutrition: NPO since midnight for possible procedure today\n Glycemic Control: Has been euglycemic, continue checking glucose with\n daily labs\n Lines:\n 16 Gauge - 04:58 PM\n 20 Gauge - 04:59 PM\n Prophylaxis:\n DVT: Heparin drip\n Stress ulcer: PPI\n Communication: Daughter \n status: Full code\n Disposition: ICU\n" }, { "category": "General", "chartdate": "2141-07-19 00:00:00.000", "description": "Generic Note", "row_id": 376941, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessments and plans as outlined during\n multidisciplinary rounds this morning. She feels better\n less pain,\n minimal SOB no different from baseline. LENI\n substantial bilat clot\n 98.4 73 90/43\n Chest quiet no rub prolonged exhalation\n P2 nl w/o m\n UO\n 10cc last hour\n PTT 112\n Doing well after signif PE. Heparin is therapeutic. Will initiate\n coumadin. UO is declining however\n I am concerned about dye load from\n CTA. We will give fluid bolus and check Una, UA. Temp has trended\n down. No evidence of infection. Echo this am. We are tolerating BPs\n of 90.\n Time spent 35 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2141-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 377040, "text": "Nursing Progress Note\n Pt is an 81 yo female w/ PMHx of cdiff colitis, MSSA pna, afib and\n atrial tachycardia, COPD, CHF w/ an EF on 55%, osteoarthritis, PAD,\n HTN, migraine HA, chronic eosinophilic lung disease and\n hypoalbuminemia. She presented to ED from nursing home w/ c/o of\n fever, cough, recent infx, and pleuritic right sided rib pain. CT\n consistent with extensive right PE, RLL opacification concerning for\n pulmonary infx. Pt\ns baseline SBP runs 90-115. In ED temp was 103 and\n SBP in 80s. Pt given vancomycin, cefepime, and Tylenol. Bolused w/ 1\n L NS and given bolus of 4900 U heparin IV and gtt initiated and running\n at 1100 units/hr. After Tylenol repeat temp at 100.5. Pt transferred\n to for further management. Upon arrival, pt afebrile but HR in\n 120s and SBP 85. Pt bolused w/ additional 500 cc\ns NS.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt\ns PTT decreased to 56.2 and INR at 1.3 at 3:00. Pt began 3 mg\n Coumadin at 1600. No signs of bleeding noted. BBS diminished\n throughout w/ no adventitious sounds noted. Pt has persistent, dry\n cough which pt explains is at baseline. Pt on 4L O2 NC with sats above\n 98%. Remains free from distress at rest, but gets SOB w/ lots of\n activity. Pt denied pain throughout shift.\n Action:\n Increased pt\ns heparin gtt to 850 U/hr per sliding scale but did not\n hep bolus per Dr. . Monitoring pt\ns respiratory status\n closely. Kept head of bed elevated and O2 at 4L/min. total of\n 15 mL robitussin throughout the night.\n Response:\n Pt maintained stable respiratory status and O2 saturation. Cough\n persisted throughout shift w/ moderate relief from Robitussin.\n Plan:\n Continue to monitor respiratory status. Continue w/ heparin per\n sliding scale and once daily coumadin therapy. Monitor both PTT and\n INR.\n Hypotension (not Shock)\n Assessment:\n Pt maintained SBP between 90 and 115 and DBP above 50. Pt\ns urinary\n output maintained around 30 ml/hr. Foley was displaced after 1:00 w/\n large incontinence noted and replaced at 3:00. Pt\ns HR 80-95. Pt\n remained A and O X 3, denied dizziness, and remained free of\n diaphoresis and distress. U/A and urine lytes still pending.\n Action:\n Monitored pt\ns hemodynamic status closely. Pt given 500 mL IVF bolus X\n 1 at 1:45 in response to lack of urine output which was actually\n secondary to foley displacement.\n Response:\n UOP > 30 ml/hr and SBP above 90.\n Plan:\n Continue to monitor hemodynamic status closely. Anticipate need for\n IVF if UOP < 30 ml/hr.\n *Pt remained afebrile w/ temps < 98\n *Pt\ns K at 3.2 w/ 3:00 labs down from 3.4. Pt denied PO forms of K, \n MD . Awaiting K from pharmacy.\n" }, { "category": "ECG", "chartdate": "2141-07-18 00:00:00.000", "description": "Report", "row_id": 111241, "text": "Sinus rhythm. Delayed R wave progression with late precordial QRS transition\nis non-specific. Otherwise, tracing may be within normal limits but baseline\nartifact makes assessment difficult. Since the previous tracing of \nno significant change.\n\n" }, { "category": "Radiology", "chartdate": "2141-07-18 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1081586, "text": " 12:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with R rib pain, temp, pleuritic\n REASON FOR THIS EXAMINATION:\n eval PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf 2:40 PM\n Extensive right PE. RLL opacification, concerning for pulmonary infarction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old woman with right rib pain, temperature, pleuritic pain.\n Evaluate for PE.\n\n TECHNIQUE: CTA chest. Coronal and sagittal reformatted images were provided.\n MIP projections provided.\n\n COMPARISON: Compared to CT chest .\n\n FINDINGS: The heart is slightly enlarged. There is calcification of the\n aorta, mitral annulus, and aortic valve. In the right lower lobe, there is\n airspace opacification, which is concerning for pulmonary infarction, but\n superinfection, aspiration, and/or partial collapse cannot be excluded.\n Atelectasis is noted within the lingula in addition to airspace opacities\n within the left lung base, which may be related to aspiration.\n No large pleural effusions are seen. There are multiple borderline enlarged\n mediastinal lymph nodes, which do not meet the CT criteria for pathologic\n enlargement, and with similar apperance comapred to prior scan. No pericardial\n effusion is seen. Multiple calcified granulomas are noted throughout the\n lungs. There are small peripheral micronodules with similar appearance\n compared to prior study.\n\n CTA CHEST: There is extensive right PE, distributing in the right main\n pulmonary artery, and in right subsegmental and segmental levels, with most\n extension in the right lower lobe.\n\n IMPRESSION:\n\n 1. Extensive PE on the right.\n\n 2. Airspace opacification in the right lower lobe, concerning for pulmonary\n infarction, but superinfection, aspiration and/or partial collapse cannot be\n excluded. Opacities at the left lung base could be related to aspiration,\n atelectasis or small infarct.\n\n 3. Multiple borderline enlarged likely reactive mediastinal lymph nodes.\n\n 4. Emphysema.\n\n 5. Multiple bilateral calcified granuloma with several noncalcified\n (Over)\n\n 12:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval PE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n micronodules.\n\n Findings were posted on the ED dashboard, and discussed by phone with Dr.\n .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1081581, "text": " 12:44 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with fevers, cough, decreased BS RLL\n REASON FOR THIS EXAMINATION:\n eval pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with fever, cough, decreased breath sounds at\n the right lower lobe, evaluate for pneumonia.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: Heart size, cardiomediastinal and hilar contours are\n normal. The aorta is calcified and unfolded. There is a small persistent\n left pleural effusion. Right basal opacification likely represents\n atelectasis. Upper lobe predominant lucency suggests emphysema. There is no\n pneumothorax. Osseous structures are grossly unremarkable.\n\n IMPRESSION:\n 1. Persistent left pleural effusion.\n 2. Right basilar opacification likely atelectasis.\n 3. Upper lobe lucency suggests emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-18 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1081648, "text": " 5:38 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: r/o DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, HTN p/w large R sided PE.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with COPD, hypertension with a large right-\n sided PE.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: There is partially occlusive\n thrombus within the right common femoral vein extending into the greater\n saphenous vein and profunda femoris vein. The remainder of the veins of the\n right lower extremity are patent. The left lower extremity shows thrombosis\n of the the left peroneal vein. The left common femoral, superficial femoral\n and popliteal veins are patent\n\n IMPRESSION:\n 1. Nonocclusive thrombus in the right common femoral vein extending into the\n greater saphenous and profunda femoris vein.\n\n 2. Left peroneal vein thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2141-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081711, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o progression of RLL infiltrate, new infiltrates, effusion\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, diastolic CHF with recent hospitalization for RLL\n PNA who p/w bilateral LE DVTs and large R sided PE.\n REASON FOR THIS EXAMINATION:\n r/o progression of RLL infiltrate, new infiltrates, effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 11:31 AM\n Opacity in right lung base is a combination of atelectasis and GGO. The GGO\n probably due to perfusion abnormality distal to known PE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female with COPD, diastolic CHF, with recent\n hospitalization for right lower lobe pneumonia who developed bilateral lower\n extremity DVTs and large right-sided PE. Rule out progression of right lower\n lobe infiltrate, new infiltrates, effusions.\n\n COMPARISON: Multiple prior studies, the most recent chest x-ray in \n and most recent chest CTA obtained in .\n\n PORTABLE AP CHEST RADIOGRAPH: Hyperlucency in the upper lobes corresponded to\n the known emphysema. The opacity in the left lower lung corresponds to a\n combination of atelectasis and ground-glass opacity demonstrated in the recent\n CAT scan. The ground-glass opacity could be due to perfusion abnormality\n distal to the pulmonary embolism. Mild cardiomegaly. Improvement of the\n atelectasis in the left lung base. Mediastinal contours appear remarkable.\n\n" }, { "category": "Radiology", "chartdate": "2141-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082020, "text": " 3:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate and pulmonary edema\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with large R PE, new increased SOB and fever\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate and pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with large right PE, now with increased\n shortness of breath and fever.\n\n COMPARISON: ; .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: Cardiomediastinal contour is\n unchanged. Again seen is right basilar opacification which, in the context of\n pulmonary embolus, could represent pulmonary hemorrhage or infarct. No other\n area of consolidation is seen. There is no pneumothorax. Osseous structures\n are grossly normal.\n\n IMPRESSION: Right basilar opacification could represent pulmonary hemorrhage\n versus infarct.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081712, "text": ", MED 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o progression of RLL infiltrate, new infiltrates, effusion\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, diastolic CHF with recent hospitalization for RLL\n PNA who p/w bilateral LE DVTs and large R sided PE.\n REASON FOR THIS EXAMINATION:\n r/o progression of RLL infiltrate, new infiltrates, effusions\n ______________________________________________________________________________\n PFI REPORT\n Opacity in right lung base is a combination of atelectasis and GGO. The GGO\n probably due to perfusion abnormality distal to known PE.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2125-11-05 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 776763, "text": " 1:27 PM\n CT TRACHEA W/C & W/RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: SQUAMOUS CELL CA,S/P STENT,ASSESS AIRWAY INVOLVEMENT OF TUMOR\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with squamous cell ca s/p stent placement\n REASON FOR THIS EXAMINATION:\n assess airway involvement of tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Squamous cell CA status post stent placement, assess airway\n involvement.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: CT chest with IV contrast. CT of the airway was performed during\n dynamic aspiration. 100 cc of Optiray was administered IV for patient's\n history of allergies.\n\n CT CHEST WITH IV CONTRAST: Soft tissue windows reveal supraclavicular lymph\n nodes on the right side, measuring approximately 16 mm in short axis. There is\n bulky right paratracheal lymph nodes, measuring approximately 2 cm in short\n axis. A large mass is present in the right hilar measuring approximately 4.4\n x 3.4 cm in size. There is associated right hilar and subcarinal\n lymphadenopathy.\n\n The right upper lobe bronchus is obstructed. The patient is status post stent\n placement in the bronchus intermedius. Soft tissue density is noted in the\n stent. Considering the proximety of the stent to the adjacent tumor this most\n likely represents tumor invasion rather than granulation tissue. The cross\n sectional area of the stent is stenosed by approximately 45%. The right\n pulmonary arteries are encased by the hilar mass, stretched and narrowed, but\n appear patent. Right middle lobe and right lower lobe bronchi appear patent.\n Trace bilateral pleural effusions are noted.\n\n Lung windows reveal a calcified granuloma in the right lung base. Diffuse air\n space ground glass opacifications are present bilaterally, left greater than\n right. Post obstructive atelectasis of the right upper lobe is seen.\n\n Expiration images demonstrate no evidence of tracheobronchomalacia.\n\n The patient also has an abdominal CT on the same day. Please see the abdominal\n CT for the full report for abdominal findings.\n\n Bone windows reveal no significant abnormalities.\n\n Expiration images reveal no excessive airway collapse that is suggestive of\n tracheobronchomalacia.\n\n IMPRESSION:\n\n (Over)\n\n 1:27 PM\n CT TRACHEA W/C & W/RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: SQUAMOUS CELL CA,S/P STENT,ASSESS AIRWAY INVOLVEMENT OF TUMOR\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Large right hilar mass obstructing the right upper lobe bronchus with post\n obstructive atelectasis of the right upper lobe. Mediastinal lymphadenopathy\n is also noted.\n\n 2. The patient is status post stent placement in right mainstem bronchus and\n bronchus intermedius. Soft tissue density is present within the stent, with\n associated luminal narrowing. This may represent tumoral involvement, and less\n likely represents granulation tissue or secretions. Note is also made of\n thickening of the wall of the right mainstem bronchus extending to its\n origin from the carina. The right middle lobe and lower lobe bronchi are\n patent.\n\n 3. Diffuse ground glass opacities in the lungs, left greater than right,\n which may represent infectious pneumonitis, drug reaction or hypersensitivity\n pneumonitis. Less likely this could represent lymphangetic carcinomatosis.\n\n\n ADDENDUM:\n Multiplanar and 3-D images were reconstructed and reviewed in conjunction with\n the axial images. They confirm the presence of right upper lobe bronchial\n obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2125-11-05 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 776764, "text": " 1:28 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: SQUAMOUS CELL CA,EVAL METS\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with squamous cell lung ca s/p bronch.\n REASON FOR THIS EXAMINATION:\n Please characterize lung mass, known squamous cell ca. Please include liver,\n adrenal cuts.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN, PELVIS .\n\n INDICATION: Squamous cell cancer. Status post bronchoscopy. Evaluate for\n metastatic disease.\n\n TECHNIQUE: CT images of the abdomen were acquired without IV contrast.\n Subsequent CT images of the abdomen were acquired in the arterial phase using\n 120 cc of IV Optiray contrast. Delayed contrast phase images of the abdomen\n and pelvis were then acquired.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There are patchy ground glass\n air-space opacities at the lung bases bilaterally, status post recent\n bronchoscopy. There is a calcified granuloma at the right lung base. There\n are multiple peripheral splenic perfusion defects. The liver, gallbladder,\n adrenal glands, kidneys, pancreas, stomach, and visualized portions of large\n and small bowel are unremarkable. There is no retroperitoneal or mesenteric\n lymphadenopathy. There are scattered arteriovascular calcifications.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is air within the bladder. The\n ureters and visualized portions of large and small bowel are unremarkable.\n\n BONE WINDOWS: Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) Patchy ground glass opacities at the lung bases bilaterally are probably\n related to recent bronchoscopy.\n\n 2) Air within the bladder. Please correlate with recent instrumentation.\n\n" }, { "category": "Radiology", "chartdate": "2125-11-05 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 776762, "text": " 1:26 PM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: SQUAMOUS CELL CA,EVAL BRAIN METS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with squamous cell lung ca s/p bronch.\n REASON FOR THIS EXAMINATION:\n ? mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lung CA, ? metastatic disease.\n\n Multiple axial images were obtained from base to vertex without and with IV\n contrast administration.\n\n There are no abnormal enhancing mass lesions seen within the brain. A tiny\n focus of increased attenuation is seen abutting the lateral aspect of the\n fourth ventricle, consistent with benign calcification. There is no\n pathologic meningeal enhancement seen. Periventricular low density is seen\n suggestive of microvascular ischemic disease. The calvarium is intact. There\n is chronic opacification of the posterior mastoid air cells. This could be\n related to a chronic inflammatory process. No lytic lesions are seen within\n the calvarium.\n\n IMPRESSION:\n\n No acute intracranial pathology is seen. There are no metastatic lesions\n identified.\n\n" }, { "category": "Echo", "chartdate": "2125-11-02 00:00:00.000", "description": "Report", "row_id": 69139, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 250\nBSA (m2): 2.32 m2\nBP (mm Hg): 104/52\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\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nLeft ventricular wall thicknesses are normal. Regional left ventricular wall\nmotion is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). There is no resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\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. Trivial mitral regurgitation is seen.\n\nTRICUSPID VALVE: There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. There is no\npulmonic valve stenosis.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality. The patient was on a ventilator.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Left ventricular wall thicknesses are normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The aortic valve leaflets are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2125-11-02 00:00:00.000", "description": "Report", "row_id": 154694, "text": "Profound irregular sinus bradycardia. Otherwise, no significant diagnostic\nabnormalities. Compared to the previous tracing of profound irregular\nsinus bradycardia is new. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2125-11-02 00:00:00.000", "description": "Report", "row_id": 154930, "text": "Normal sinus rhythm. Minor non-diagnostic T wave changes. No previous tracing\navailable for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-11-02 00:00:00.000", "description": "Report", "row_id": 1276404, "text": "Received pt. from Hospital at 2210. Pt. remains intubated with a 7.0 ETT at 22cm. Chest movement is symmetrical and breathe sounds are audible and documented on flowsheet. O2 sats read 96-100% on 60% fio2. ABG drawn with no changes made. Plans to send pt. to the O.R. as an add on case for a rigid bronch with possible stent placement. No orders for this have officially been written. Pt. is agitated upon arrival to and is sedated with versed/fentyl and finally propofol and a fentyl gtt. Pt. arouses to verbal stimuli. and easily becomes agitated upon suctioning and repositioning. Steristrips to upper chest remain D&I this is the insertion site from the mediastinoscopy from . Plans to change out EET for larger one to be done in the OR this comes via Resp. therapist. Pt. remains at this time stable on fentyl gtt. Troponin did come back elevated with M.D's aware and orders written and carried out by nurse.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-02 00:00:00.000", "description": "Report", "row_id": 1276405, "text": "Nursing Progress Note.\n\nRESP: Pt received resting fairly comfortably on MV c the following resting settings; AC-16-60-500-7.5. Sats on these settings were in the high 90's, RR in the teens and no overt evidence of resp distress/SOB evident. 07:30 ABG drawn/sent c the following values; 7.38-44-123, FiO2 subsequently dropped to 50% c good pt tol thus far. Repeat ABG drawn/sent while pt agitated @ 11:00; 7.35-48-77 -- pt subsequently sedated c IV Propofol c + affect. Sats have been in the high 90's, RR in the teens. Pt bronched @ BS this AM, R mainstem bronchus occlusion comfirmed. Pt presently waiting to go for rigid brochoscopy in OR for stent placement. Have exp diff securing ETT to pt 2nd pt's beard and pt has had a small air leak for much of day. Large airway placed freq and ETT tape re-applied multiple times to ameliorate this problem c some success -- pt cont to receive the full volume of 500ml set by the vent. LS are diminished/absent on the L side, +rhonchi on R side c faint/scattered Exp wheeze also appreciated. Pt presently overbreathing vent by 1-4 breaths/min c a sat of 96%. The pt is on Levofloxacin and Metronidazole per OGT for possible post-ob PNA. S/p stent placement expect to initiate vent weaning c possible extubation possible.\n\nCV: HDSA, sinus bradycardic. R radial A-Line in place c optimal pleth noted. 12.5mg Lopressor provided Q12hr as ordered. 3rd CPK sent, values cont to decline c 11:00 lab value = 53. Per Cardiology, cardiac ischemia/event unlikely in this pt at this time and therefore pt is okay to go for rigid bronchoscopy/stent placement later today. No peripheral edema evident. Adequate UO. Normoglycemic thus far today. D5 1/2NS infusion started, infusing @ 100ml/hr via. Three intact PIV's in place and operational. Echocardiogram performed @ BS this AM. QD 60mg oral Prednisone therapy started today via OGT.\n\nGI: NPO x meds per OGT. No stool output today. Abd is soft, +BS, NT.\n\nMS: Pt med presently c IV Fentanyl @ 150mcg/hr (for chronic/severe back pain) and IV Propofol @ 23mcg/kg/min (for sedation) c adequate sedation achieved thus far. Attempting to titrate Fentanyl down and Propofol up for more optimal sedation. Pt responds to voice and follows command. UE restrained to protect ETT.\n\nDERM: No issues at this time. Mediastinal incision D & I. Pt prefers to lie on his L side 2nd chronic/severe back pain.\n\nFAMILY: Wife, dtr, sister have visited today and kept abreast of POC/pt status. The family is quite anxious for the pt to go to the OR for stent placement. The pt is a full code. Universal isolation in place.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-11-03 00:00:00.000", "description": "Report", "row_id": 1276406, "text": "pt arrived from bronch/stent procedure at start of shift.\n\nCNS- sedated with propofol/fentanyl gtt. peerl. gtt slowed to let pt rouse. pt alert, following commands, nodding understanding. pt asked to be resedated to sleep through the night.\n\nCV- afebrile. sb, no ectopy noted. vss, wnl. art line dampened at times, though giving consistant readings.\n\n pt reintubated following procedure, before coming to unit. cxr for placement done in unit. #8 @ 22cm. lungs now coarse t/o with occ. insp wheezes. see resp notes/flowsheet for details.\n\nGI- abd soft, bt+. ngt in place, clamped. + placement.\n\nGU- clear yellow uop; qs.\n\nposs extubation this am/afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-03 00:00:00.000", "description": "Report", "row_id": 1276407, "text": "Nursing Progress Note.\n\nRESP: Pt received resting comfortably on MV c the following settings; AC-18-50-550-7.5. Pt 03:00 ABG values; 7.41-50-156. 08:00 sats in high 90's, RR in the teens, sxn'ing pt Q2-3 hours for thick bloody tinged secretions and per pt self report - no significant resp c/o. 08:45 CPAP/PS (7.5/5.0) c 50% FiO2 trial initiated c good tol and good subsequent ABG @ 09:30; 7.42-50-163. FiO2 then dropped to 40% and pressure support dropped to 5 by RT. Repeat ABG @ 10:40; 7.42-50-99. RT then obtained resp mech values (WNL) and the pt was extubated successfully to 40% CSM @ 12:50. LS fairly equal on both sides, mildly diminished in RLL, no wheezing appreciated. Pt now on 50% CSM c last ABG values of; 7.47-43-59, pt's sat is now 96%, RR is in the teens. Pt exhibiting strong cough, producing thick blood tinged/mucoid sec. Pt denies SOB/dyspnea presently. Nebs provided by RT.\n\nCV: HDSA. NSR/sinus bradycardia. No ectopy. AM PO Lopressor held 2nd bradycardia. Adequate UO. No lyte repletion necessary c AM labs. Normoglycemic thus far today. Per team, pt dx c a +NQWMI during this acute illness. Echocardiogram EF = 55-60%.\n\nGI: NGT d/c'ed c extubation. Pt started on ice chips (sparingly) s/p extubation. Abd exam is benign. No BM. Rectal exam this am guaic negative.\n\nMS: Propofol gtt rapidly weaned off this AM to expedite extubation c good pt comfort. Fentanyl gtt currently infusing @ 125mcg/hr for chronic/severe back pain c adeq control (position changes and back rubs also provided c + relief per pt). Expect to wean Fentanyl gtt off once pt is able to take PO's safely again. Pt is currently AAO times three, pleasant/cooperative, NAD, following commands and is purposeful.\n\nDERM: No issues @ this time.j\n\nFAMILY: Wife, dtr, sister currently visiting @ BS and kept abreast of pt /status. They are relieved that pt is off vent and appears to be doing well. The pt is a full code. Universal isolation is in place.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n" } ]

[ { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543987, "text": "Hypotension (not Shock)\n Assessment:\n Hypotensive and Remains on levo gtt to keep map > 60.\n Action:\n Levo gtt. Ivf. 1 u prbc\ns given.\n Response:\n Aline positional. Remains on levo gtt but weaning down. u/o improved.\n Plan:\n Con\nt to monitor closel;y. wean levo gtt as tol.\n Sepsis without organ dysfunction\n Assessment:\n Febrile with rigors. Requiring pressors and ivf. Tachy to 160\n Action:\n . Abx. Ivf. 1 u prbc\ns. had abd/chest/pelvis ct.\n Response:\n Temp down to 98.7. bp improving and pressor requirement decreasing. Ivf\n decreased. Awaiting post tx labs. Hr down to 90\n Plan:\n Monitor closely. Follow temp. abx. Support. Follow labs.\n" }, { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543988, "text": "Hypotension (not Shock)\n Assessment:\n Hypotensive and Remains on levo gtt to keep map > 60.\n Action:\n Levo gtt. Ivf. 1 u prbc\ns given.\n Response:\n Aline positional. Remains on levo gtt but weaning down. u/o improved.\n Plan:\n Con\nt to monitor closel;y. wean levo gtt as tol.\n Sepsis without organ dysfunction\n Assessment:\n Febrile with rigors. Requiring pressors and ivf. Tachy to 160\n Action:\n . Abx. Ivf. 1 u prbc\ns. had abd/chest/pelvis ct.\n Response:\n Temp down to 98.7. bp improving and pressor requirement decreasing. Ivf\n decreased. Awaiting post tx labs. Hr down to 90\n Plan:\n Monitor closely. Follow temp. abx. Support. Follow labs.\n Hypoxemia\n Assessment:\n Required 100% nrb this am. Sats down to 88 when off. Pt did c/o sob and\n had audible wheezes. was on commode at time and was very anxious.\n team aware. resolved after ativan. Ls clear.\n Action:\n O2. c+db enc. Had chest ct.\n Response:\n Pt has pnx. Remains on abx. O2 able to be weaned from 100% nrb to 6l\n face mask. Ls remain clear. Nard noted at this time.\n Plan:\n Abx. Pulm hygiene. Wean o2 as tol\n" }, { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543989, "text": "Hypotension (not Shock)\n Assessment:\n Hypotensive and Remains on levo gtt to keep map > 60.\n Action:\n Levo gtt. Ivf. 1 u prbc\ns given.\n Response:\n Aline positional. Remains on levo gtt but weaning down. u/o improved.\n Plan:\n Con\nt to monitor closel;y. wean levo gtt as tol.\n Sepsis without organ dysfunction\n Assessment:\n Febrile with rigors. Requiring pressors and ivf. Tachy to 160\n Action:\n . Abx. Ivf. 1 u prbc\ns. had abd/chest/pelvis ct.\n Response:\n Temp down to 98.7. bp improving and pressor requirement decreasing. Ivf\n decreased. Awaiting post tx labs. Hr down to 90\n Plan:\n Monitor closely. Follow temp. abx. Support. Follow labs.\n Hypoxemia\n Assessment:\n Required 100% nrb this am. Sats down to 88 when off. Pt did c/o sob and\n had audible wheezes. was on commode at time and was very anxious.\n team aware. resolved after ativan. Ls clear.\n Action:\n O2. c+db enc. Had chest ct.\n Response:\n Pt has pnx. Remains on abx. O2 able to be weaned from 100% nrb to 6l\n face mask. Ls remain clear. Nard noted at this time.\n Plan:\n Abx. Pulm hygiene. Wean o2 as tol\n" }, { "category": "Physician ", "chartdate": "2170-12-17 00:00:00.000", "description": "Intensivist Note", "row_id": 544324, "text": "SICU\n HPI:\n 58yoF with cholangioCa, mets to sigmoid presented with fever 104.0 and\n hypotension to 70s.\n Chief complaint:\n PMHx:\n Past Medical History:\n PMH: Hypothyroidism, R Kidney stones, cholangioCarcinoma- metastatic\n PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,\n Tonsillectmy and adenoidectomy, Colonoscopy many years ago\n Current medications:\n Acetaminophen 4. Calcium Gluconate 5. Ciprofloxacin 6. Docusate Sodium\n 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Influenza Virus Vaccine 10.\n Insulin 11. Labetalol 12. Levothyroxine Sodium 13. Lorazepam 14.\n Magnesium Sulfate 15. MetRONIDAZOLE (FLagyl) 16. Metoprolol Tartrate\n 17. Meperidine 18. Norepinephrine 19. Pantoprazole 20.\n Piperacillin-Tazobactam Na 21. Potassium Chloride 22. Prochlorperazine\n 23. Senna 24. Sodium Chloride 0.9% Flush 25. Ursodiol 26. Xopenex\n 24 Hour Events:\n STOOL CULTURE - At 10:55 AM\n for o+p\n BLOOD CULTURED - At 06:49 AM\n FEVER - 101.4\nF - 06:00 AM\nRespiratory distress early this AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:29 PM\n Ciprofloxacin - 05:26 AM\n Metronidazole - 08:57 AM\n Piperacillin/Tazobactam (Zosyn) - 08:57 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:01 AM\n Meperidine (Demerol) - 06:30 AM\n Lorazepam (Ativan) - 06:30 AM\n Heparin Sodium (Prophylaxis) - 08:57 AM\n Pantoprazole (Protonix) - 08:58 AM\n Other medications:\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.1\nC (98.8\n HR: 87 (87 - 132) bpm\n BP: 103/65(82) {97/48(68) - 165/109(117)} mmHg\n RR: 29 (16 - 41) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.3 kg (admission): 52.3 kg\n CVP: 7 (2 - 224) mmHg\n Total In:\n 2,569 mL\n 1,269 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,569 mL\n 1,269 mL\n Blood products:\n Total out:\n 1,652 mL\n 455 mL\n Urine:\n 1,652 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 917 mL\n 814 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: 7.42/28/158/22/-4\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: Bilat bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 227 K/uL\n 8.7 g/dL\n 119 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 111 mEq/L\n 138 mEq/L\n 26\n 18.5 K/uL\n [image002.jpg]\n 05:56 AM\n 06:04 AM\n 06:23 AM\n 04:41 PM\n 08:41 PM\n 04:07 AM\n 05:13 PM\n 03:15 AM\n 06:02 AM\n 06:46 AM\n WBC\n 7.0\n 10.1\n 41.9\n 39.2\n 18.5\n Hct\n 22.6\n 22.7\n 27.6\n 26.2\n 29\n 25.4\n 30\n 26\n Plt\n 394\n 358\n 376\n 312\n 227\n Creatinine\n 0.6\n 0.8\n 0.7\n 0.7\n Troponin T\n 0.06\n TCO2\n 18\n 20\n 22\n 20\n 19\n Glucose\n 132\n 113\n 96\n 91\n 119\n Other labs: PT / PTT / INR:19.3/31.5/1.8, CK / CK-MB / Troponin\n T:18//0.06, ALT / AST:29/22, Alk-Phos / T bili:280/0.6, Lactic Acid:1.0\n mmol/L, Albumin:2.0 g/dL, LDH:163 IU/L, Ca:7.7 mg/dL, Mg:1.7 mg/dL,\n PO4:2.0 mg/dL\n Assessment and Plan\n HYPOXEMIA, HYPOTENSION (NOT SHOCK), SEPSIS WITHOUT ORGAN DYSFUNCTION,\n .H/O TACHYCARDIA, OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Dilaudid prn pain\n Cardiovascular: Doubt primary cardiac event with ECG demonstrating only\n flattened T-waves anterior --> finish cycling enzymes and remain on\n tele. Cont lopressor\n Pulmonary: CTA for PE; Would also consider thoracentesis today as I\n believe her effusions are contributing to her respiratory distress.\n Gastrointestinal / Abdomen:\n Nutrition: Sips of clears --> consider advance diet later today.\n Renal: Foley, Adequate UO, Lasix x1 now.\n Hematology:\n Endocrine: RISS\n Infectious Disease: Cont Vanco/Zosyn and d/c Cipro --> while awaiting\n speciation of GNR's, will talk to ID regarding double coverage of GNR.\n Lines / Tubes / Drains: Foley, CVL\n Wounds: none\n Imaging: CXR today\n Fluids: KVO, KVO IVF\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress), Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:59 AM\n Multi Lumen - 07:48 AM\n 16 Gauge - 08:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\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": "2170-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544551, "text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543908, "text": "dx: with cholangiocarcinoma 1 month ago s/p stenting at .\n discharged from hospital yesterday . presented at hospital\n with fever to 104 and rt sided abd pain. sbp in the 70's. started on\n dopamine and transferred to . in er. dopa off. fluid resusitated\n with 6l of ns. blood cultures sent. pt tachy to 130's. o2 sat down to\n 90 and changed to non rebreather with 02 sat of 95%. abd ultrasound\n done in er. tylenol given for temp.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from the er with tachycardia to 150\ns. and sbp 118/60. pt on\n nonrebreather with o2 sat of 94-97%. Pt c/o dyspnea and unable to lay\n flat. Cxr and abd xray done. Fluid boluses of 2l finished. Sbp down to\n 70\ns. after fluid bolus finished. Hr down to 118 st. pt states\n breathing is more comfortable and resp rate down to 22 and o2 sat 100%\n on 100% nonrebreather.\n Action:\n Aline placed. Repeat labs drawn. Levophed drip started and titrated up\n to .1mcg/kg/min.\n Response:\n Sbp 90\ns/ 50\ns. hr remains in the 110\n Plan:\n Await lab results. Increase fluid to 250cc/hr. antibiotics as ordered.\n Monitor culture results.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543898, "text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2170-12-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 543906, "text": "dx: with cholangiocarcinoma 1 month ago s/p stenting at .\n discharged from hospital yesterday . presented at hospital\n with fever to 104 and rt sided abd pain. sbp in the 70's. started on\n dopamine and transferred to . in er. dopa off. fluid resusitated\n with 6l of ns. blood cultures sent. pt tachy to 130's. o2 sat down to\n 90 and changed to non rebreather with 02 sat of 95%. abd ultrasound\n done in er. tylenol given for temp.\n Sepsis without organ dysfunction\n Assessment:\n Pt arrived from the er with tachycardia to 150\ns. and sbp 118/60. pt on\n nonrebreather with o2 sat of 94-97%. Pt c/o dyspnea and unable to lay\n flat. Cxr and abd xray done. Fluid boluses of 2l finished. Sbp down to\n 70\ns. after fluid bolus finished. Hr down to 118 st. pt states\n breathing is more comfortable and resp rate down to 22 and o2 sat 100%\n on 100% nonrebreather.\n Action:\n Aline placed. Repeat labs drawn. Levophed drip started and titrated up\n to .1mcg/kg/min.\n Response:\n Sbp 90\ns/ 50\ns. hr remains in the 110\n Plan:\n Await lab results. Increase fluid to 250cc/hr. antibiotics as ordered.\n Monitor culture results.\n" }, { "category": "Nursing", "chartdate": "2170-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544411, "text": "Hypoxemia\n Assessment:\n In AM pt. on 100% face mask, breathing appeared labored and tachypneic,\n sats 93-96%; LS coarse with fine crackles in bases.\n Action:\n Administered 20 mg lasix IV; CTA to r/o P.E.\n Response:\n Patient diuresed 1.5 L urine; weaned oxygen to 6L N/C; appeared far\n more comfortable with breathing and said she was breathing easier, no\n longer tachypneic. LS clear, diminished in bases. CT scan and bilateral\n lower extremities ultrasounds negative.\n Plan:\n Continue to closely monitor; possible thoracentesis tomorrow for large\n pleural effusions in bases\n" }, { "category": "Nursing", "chartdate": "2170-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544225, "text": "Sepsis without organ dysfunction\n Assessment:\n Tmax 99.9. u/o improved. Map >65.\n Action:\n Remains on abx. Ivf changed to maintenance fluid, levo weaned off.\n Response:\n Tol well. Sepsis seems to be improving.\n Plan:\n Con\nt to monitor closely. Follow temp. abx.\n Hypoxemia\n Assessment:\n O2 sat 97% on 4l nc and 40% face tent. Wearing face tent prn for\n comfort. Does desat without it at time. Ls clear, decreased at right\n base. Tachypnea to 30\ns at times but appears comfortable and not\n labored. No sputum\n Action:\n O2 weaned. Pulm hygiene enc.\n Response:\n Improving hypoxemia,\n Plan:\n Con\nt pulm hygiene. Abx for pna.\n Hypotension (not Shock)\n Assessment:\n Map >65.\n Action:\n Levo weaned off this am.\n Response:\n Bp remains stable off pressors.\n Plan:\n Follow closely.\n" }, { "category": "Nursing", "chartdate": "2170-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544554, "text": "58yo F with cholangiocarcinoma a/w septic shock, RML infiltrate, asc\n colon thickening.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, BP 100s-50s, pt denies pain, moves all extremities, AAOx3,\n VSS\n Action:\n Zosyn & flagyl IV given as ordered\n Response:\n Pt stable\n Plan:\n Continue IV abx as ordered, monitor VS\n Pleural effusion, acute\n Assessment:\n Lungs CTA upper lobes, decreased at bases, O2 infusing via NC at\n 5L/min, O2 sat > 94%, pt reports slight SOB with movement. RR = 20-30.\n Action:\n 20 mg Lasix IV given as ordered\n Response:\n Goal fluid status euvolemic to slightly negative, approx 800 cc off 2\n hrs\n Plan:\n Continue to monitor fluid status, respiratory status\n Nausea / vomiting\n Assessment:\n Pt complains of nausea\n Action:\n 5 mg compazine IV given as ordered q 6 hrs\n Response:\n Pt reports relief of nausea, pt able to eat lunch\n Plan:\n Continue to monitor GI status\n" }, { "category": "Nursing", "chartdate": "2170-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544300, "text": "Hypoxemia\n Assessment:\n Pt rang call llight complaining of difficulty breathing. Hr 130\ns. bp\n 180\ns. resp rate 40\ns. breath sounds wheezes. Skin pale.and having\n rigors. Temp 101.4 k 3.1, ion ca 1.08\n Action:\n Lopressor 5mg iv x1 given. Abg drawn. Ativan 0.5mg iv x2 given.\n Demerol 12.5mg iv x1 given. Blood culture peripherally x1 given. Chest\n xray done. Ekg done.. resp rx done. Magnesium 2gms Iv givn. Potassium\n chloride 40meq k cl given. Calicium gluconate 2gms iv given.\n Response:\n Heart rate down to 99, bp 100syst. 100% face mask on. O2sat 99%. Resp\n rate20\ns. chest cta to be done today. Ultrasound of lower extremities\n to be done today. Chest xray ? diuresis.\n Plan:\n Monitor resp status closely. ? diuresis.\n" }, { "category": "Nursing", "chartdate": "2170-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544444, "text": "SICU\n HPI:\n 58yoF with cholangioCa, mets to sigmoid presented with fever 104.0 and\n hypotension to 70s.\n Chief complaint: fever, hypotension\n PMHx:\n Past Medical History:\n PMH: Hypothyroidism, R Kidney stones, cholangioCarcinoma- metastatic\n PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,\n Tonsillectmy and adenoidectomy, Colonoscopy many years ago\n Hypoxemia\n Assessment:\n s/p lasix yesterday, w/ good diuretic effect\n Action:\n Pt remains on 6 l nc O2 overnight w/ good O2 sats\n Response:\n Comfortable at rest, some SOB noted w/ activity; lungs clear, though\n dim bil bases\n Plan:\n Cont to follow resp exam\n Sepsis without organ dysfunction\n Assessment:\n Pt w/ e-coli sepsis\n Action:\n Receiving IV Abx as ordered\n Response:\n No T spikes this noc, though low grade febrile to 99.7\n Plan:\n Cont abx per plan, follow exam\n" }, { "category": "Physician ", "chartdate": "2170-12-18 00:00:00.000", "description": "Intensivist Note", "row_id": 544501, "text": "SICU\n HPI:\n 58yoF with cholangioCa, mets to sigmoid, presented with fever 104.0 and\n hypotension to 70s\n Chief complaint:\n Fever, hypotension\n PMHx:\n PMH: Hypothyroidism, R Kidney stones, cholangioCarcinoma- metastatic\n PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,\n Tonsillectmy and adenoidectomy, Colonoscopy many years ago\n Current medications:\n 2. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 3. Acetaminophen 4.\n Calcium Gluconate 5. Docusate Sodium\n 6. Furosemide 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Influenza Virus\n Vaccine 10. Insulin 11. Levothyroxine Sodium 12. Lorazepam 13.\n Magnesium Sulfate 14. MetRONIDAZOLE (FLagyl) 15. Norepinephrine 16.\n Pantoprazole\n 17. Piperacillin-Tazobactam Na 18. Potassium Chloride 19.\n Prochlorperazine 20. Senna 21. Sodium Chloride 0.9% Flush 22. Ursodiol\n 23. Zolpidem Tartrate\n 24 Hour Events:\n EKG - At 08:00 AM\n ULTRASOUND - At 08:49 AM\n bilateral lower extremities\n BLOOD CULTURED - At 01:04 PM\n URINE CULTURE - At 02:00 PM\n STOOL CULTURE - At 04:05 PM\n ARTERIAL LINE - STOP 05:18 PM\n Post operative day:\n POD #7 s/p stent placement in CBD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:29 PM\n Ciprofloxacin - 05:26 AM\n Metronidazole - 11:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:19 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:58 AM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Hydromorphone (Dilaudid) - 10:30 PM\n Other medications:\n Flowsheet Data as of 08:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.3\nC (99.2\n HR: 80 (78 - 95) bpm\n BP: 120/64(76) {94/52(58) - 132/79(81)} mmHg\n RR: 24 (17 - 31) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 54.5 kg (admission): 52.3 kg\n CVP: 10 (2 - 11) mmHg\n Total In:\n 1,919 mL\n 240 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,919 mL\n 240 mL\n Blood products:\n Total out:\n 3,890 mL\n 530 mL\n Urine:\n 3,890 mL\n 495 mL\n NG:\n Stool:\n 35 mL\n Drains:\n Balance:\n -1,971 mL\n -290 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\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: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 168 K/uL\n 9.4 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 107 mEq/L\n 140 mEq/L\n 26.5 %\n 19.8 K/uL\n [image002.jpg]\n 08:41 PM\n 04:07 AM\n 05:13 PM\n 03:15 AM\n 06:02 AM\n 06:46 AM\n 10:47 AM\n 02:02 PM\n 06:23 PM\n 02:02 AM\n WBC\n 39.2\n 18.5\n 19.8\n Hct\n 26.2\n 29\n 25.4\n 30\n 26\n 26.5\n Plt\n \n Creatinine\n 0.7\n 0.7\n 0.6\n 0.6\n Troponin T\n 0.06\n 0.06\n 0.06\n TCO2\n 20\n 22\n 20\n 19\n Glucose\n 91\n 119\n 113\n 104\n Other labs: PT / PTT / INR:15.0/26.4/1.3, CK / CK-MB / Troponin\n T:15//0.06, ALT / AST:29/22, Alk-Phos / T bili:280/0.6, Lactic Acid:1.0\n mmol/L, Albumin:2.0 g/dL, LDH:163 IU/L, Ca:7.9 mg/dL, Mg:1.9 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n HYPOXEMIA, HYPOTENSION (NOT SHOCK), SEPSIS WITHOUT ORGAN DYSFUNCTION,\n .H/O TACHYCARDIA, OTHER\n Assessment and Plan: 58yoF with cholangioCa, mets to sigmoid, presented\n with fever 104.0 and hypotension to 70s, now w/ bilateral pleural\n effusions\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Cont Dilaudid PRN\n Pain\n Cardiovascular: No issues overnight.\n Pulmonary: IS, Improved Respiratory status after diuresis, cont wean\n FiO2; OOB and Phys Therapy.\n Gastrointestinal / Abdomen:\n Nutrition: Clear liquids, Advance diet as tolerated , Discuss diet with\n Primary team.\n Renal: Foley, Adequate UO, Cont Lasix for goal Euvolemia\n Hematology: Hct relatively unchanged.\n Endocrine: RISS\n Infectious Disease: Cont Flagyl and Zosyn --> cont check C Diff x 3\n Lines / Tubes / Drains: Foley, CVL\n Wounds:\n Imaging: None\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress), Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 07:48 AM\n 16 Gauge - 08:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2170-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544760, "text": "Patient is a 58 y/o female with a PMH of hypothyroidism, R kidney\n stones, tonsillectomy, adenoidectomy, ? ovarian cyst. One month h/o\n choleangio CA, s/p stenting at 2 weeks ago; discharged from \n then presented to OSH on febrile to 104 and hypotensive to 70s.\n blood culture bottles + for e. coli. Fluid resuscitated and briefly\n on levophed. Ruled out for PE. Bilateral pleural effusions\n team\n decided not to perform thoracentesis at this time. Diuresed with Lasix\n on and with good effect; respiratory status has improved\n considerably. On zosyn and PO flagyl.\n Pleural effusion, acute\n Assessment:\n Patient on 4L N/C, RR 12-20, sats 95-98%, lung sounds clear but\n diminished at the bases; most recent CXR reports slight increase in\n bilateral pleural effusions\n Action:\n Encourage patient to deep breathe/IS; OOB to commode and frequently\n turning in bed independently to maximize lung expansion\n Response:\n Weaned N/C to 3L; continues to report that her breathing relatively\n comfortable, only very slightly winded on activity i.e. getting OOB.\n Sats 95-98%, LS diminished in R base.\n Plan:\n Possibly diurese w/ Lasix later today; thoracentesis for pleural\n effusions on hold for now; continue IS/deep breathing\n" }, { "category": "Nursing", "chartdate": "2170-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544761, "text": "Patient is a 58 y/o female with a PMH of hypothyroidism, R kidney\n stones, tonsillectomy, adenoidectomy, ? ovarian cyst. One month h/o\n choleangio CA, s/p stenting at 2 weeks ago; discharged from \n then presented to OSH on febrile to 104 and hypotensive to 70s.\n blood culture bottles + for e. coli. Fluid resuscitated and briefly\n on levophed. Ruled out for PE. Bilateral pleural effusions\n team\n decided not to perform thoracentesis at this time. Diuresed with Lasix\n on and with good effect; respiratory status has improved\n considerably. On zosyn and PO flagyl.\n Pleural effusion, acute\n Assessment:\n Patient on 4L N/C, RR 12-20, sats 95-98%, lung sounds clear but\n diminished at the bases; most recent CXR reports slight increase in\n bilateral pleural effusions\n Action:\n Encourage patient to deep breathe/IS; OOB to commode and frequently\n turning in bed independently to maximize lung expansion\n Response:\n Weaned N/C to 3L; continues to report that her breathing relatively\n comfortable, only very slightly winded on activity i.e. getting OOB.\n Sats 95-98%, LS diminished in R base.\n Plan:\n Possibly diurese w/ Lasix later today; thoracentesis for pleural\n effusions on hold for now; continue IS/deep breathing\n ------ Protected Section ------\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n CHOLANGITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 52.3 kg\n Daily weight:\n 54.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: dx: with cholangiocarcinoma 1 month ago s/p\n stenting at . discharged from hospital yesterday . presented at\n hospital with fever to 104 and rt sided abd pain. sbp in\n the 70's. started on dopamine and transferred to . in er. dopa\n off. fluid resusitated with 6l of ns. blood cultures sent. pt tachy to\n 130's. o2 sat down to 90 and changed to non rebreather with 02 sat of\n 95%. abd ultrasound done in er. tylenol given for temp.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:53\n Temperature:\n 98.8\n Arterial BP:\n S:120\n D:65\n Respiratory rate:\n 17 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 3 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 861 mL\n 24h total out:\n 782 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 02:13 AM\n Potassium:\n 3.3 mEq/L\n 11:28 AM\n Chloride:\n 104 mEq/L\n 02:13 AM\n CO2:\n 30 mEq/L\n 02:13 AM\n BUN:\n 10 mg/dL\n 02:13 AM\n Creatinine:\n 0.6 mg/dL\n 02:13 AM\n Glucose:\n 101 mg/dL\n 02:13 AM\n Hematocrit:\n 27.2 %\n 02:13 AM\n Finger Stick Glucose:\n 116\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: SICU B\n Transferred to: 10\n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 18:10 ------\n" }, { "category": "Physician ", "chartdate": "2170-12-16 00:00:00.000", "description": "Intensivist Note", "row_id": 544114, "text": "SICU\n HPI:\n 58yoF with cholangioCa, mets to sigmoid presented with fever 104.0 and\n hypotension to 70s.\n Chief complaint:\n hypotension, fever, ?aspiration pneumonia\n PMHx:\n PMH: Hypothyroidism, R Kidney stones, cholangioCarcinoma- metastatic\n PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,\n Tonsillectmy and adenoidectomy, Colonoscopy many years ago\n Current medications:\n Acetaminophen 4. Calcium Gluconate 5. Ciprofloxacin 6. Docusate Sodium\n 7. HYDROmorphone (Dilaudid)\n 8. Heparin 9. Influenza Virus Vaccine 10. Insulin 11. Levothyroxine\n Sodium 12. Levalbuterol HCl\n 13. Lorazepam 14. Magnesium Sulfate 15. Meperidine 16. Norepinephrine\n 17. Pantoprazole 18. Piperacillin-Tazobactam Na\n 19. Potassium Chloride 20. Prochlorperazine 21. Senna 22. Sodium\n Chloride 0.9% Flush 23. Ursodiol\n 24. Vancomycin\n 24 Hour Events:\n STOOL CULTURE - At 03:02 PM\n for cdiff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:29 PM\n Piperacillin/Tazobactam (Zosyn) - 11:50 PM\n Ciprofloxacin - 05:38 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 08:26 PM\n Lorazepam (Ativan) - 06:07 AM\n Other medications:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.7\nC (99.8\n HR: 90 (0 - 157) bpm\n BP: 121/106(112) {79/44(55) - 158/122(126)} mmHg\n RR: 25 (16 - 32) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 52.3 kg (admission): 52.3 kg\n CVP: 6 (6 - 17) mmHg\n Total In:\n 13,626 mL\n 977 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,976 mL\n 977 mL\n Blood products:\n 250 mL\n Total out:\n 2,615 mL\n 780 mL\n Urine:\n 2,615 mL\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 11,011 mL\n 197 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SPO2: 94%\n ABG: 7.39/32/137/21/-4\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 312 K/uL\n 9.4 g/dL\n 91 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.3 mEq/L\n 11 mg/dL\n 112 mEq/L\n 142 mEq/L\n 26.2 %\n 39.2 K/uL\n [image002.jpg]\n 05:56 AM\n 06:04 AM\n 06:23 AM\n 04:41 PM\n 08:41 PM\n 04:07 AM\n WBC\n 7.0\n 10.1\n 41.9\n 39.2\n Hct\n 22.6\n 22.7\n 27.6\n 26.2\n Plt\n 394\n 358\n 376\n 312\n Creatinine\n 0.6\n 0.8\n 0.7\n TCO2\n 18\n 20\n Glucose\n 132\n 113\n 96\n 91\n Other labs: PT / PTT / INR:19.3/31.5/1.8, CK / CK-MB / Troponin T:25//,\n ALT / AST:49/54, Alk-Phos / T bili:391/1.2, Lactic Acid:1.8 mmol/L,\n Albumin:2.4 g/dL, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HYPOXEMIA, HYPOTENSION (NOT SHOCK), SEPSIS WITHOUT ORGAN DYSFUNCTION,\n .H/O TACHYCARDIA, OTHER\n Assessment and Plan: 58yoF with cholangioCa, mets to sigmoid presented\n with GNR bacteremia and sepsis.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain free. D/C\n dilaudid order as pt does not need it. Ativan prn. Try to minimize as\n much as possible.\n Cardiovascular: Hypotension improving. Wean levophed to off.\n Pulmonary: Aspiration pneumonia on CXR but no sputum production. Stable\n otherwise\n Gastrointestinal / Abdomen: Colitis on CT abdomen, but asymptomatic.\n Send C-diff if stool\n Nutrition: NPO\n Renal: Foley, Adequate UO, Once levophed is off, switch fluids to\n maintenance\n Hematology: Serial Hct, Stable anemia. Monitor. Would not trasfuse at\n this point\n Endocrine: RISS, BG well controlled. Keep < 150\n Infectious Disease: Check cultures, GNR bacteremia. Zosyn/cipro and\n vancto for Abx. Would d/c vanco as GNR\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: LR\n Consults: Transplant\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:59 AM\n Multi Lumen - 07:48 AM\n 16 Gauge - 08:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: ICU\n Total time spent: 20 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2170-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544102, "text": "Hypoxemia\n Assessment:\n Sitting in bed at 45 degrees. Lying supine. Face mask on and o2sat 96%\n resp rate 20-30\ns. coughing and raising small amt of thick white\n sputum. O2 mask changed to 4liters of nasal prongs o2sat 94%. Wbc 39.2\n Action:\n Head of bed continues to be elevated, chest xray to be checked, chest\n ct done and results pending. Iv antibiotics, cipro, vanco and\n pipercillin.\n Response:\n Pt has [pnueumonia, on iv vanco, iv cipro and iv pipercillin.\n Plan:\n Pulmonary toileting, monitor resp status closely.\n" }, { "category": "Nursing", "chartdate": "2170-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544588, "text": "58yo F with cholangiocarcinoma a/w septic shock, RML infiltrate, asc\n colon thickening.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, BP 100s-50s, pt denies pain, moves all extremities, AAOx3,\n VSS\n Action:\n Zosyn & flagyl IV given as ordered\n Response:\n Pt stable\n Plan:\n Continue IV abx as ordered, monitor VS\n Pleural effusion, acute\n Assessment:\n Lungs CTA upper lobes, decreased at bases, O2 infusing via NC at\n 5L/min, O2 sat > 94%, pt reports slight SOB with movement. RR = 20-30.\n Action:\n 20 mg Lasix IV given as ordered\n Response:\n Goal fluid status euvolemic to slightly negative, approx 800 cc off 2\n hrs\n Plan:\n Continue to monitor fluid status, respiratory status\n Nausea / vomiting\n Assessment:\n Pt complains of nausea\n Action:\n 5 mg compazine IV given as ordered q 6 hrs\n Response:\n Pt reports relief of nausea, pt able to eat lunch\n Plan:\n Continue to monitor GI status\n" }, { "category": "Social Work", "chartdate": "2170-12-19 00:00:00.000", "description": "Social Work Progress Note", "row_id": 544728, "text": "Pt is a 58 yr old single woman known to this worker from her last\n admission. Pt diagnosed with cholangio carcinoma after having sought\n tx for severe constipation with a nutritionist. Pt involved with\n alternative therapies in her life, working well with medical\n professionals.\n Pt appropriately overwhelmed with new dx but well supported by life\n long friends and her sister . Pt has kept her friends aware of\n her medical situation, friends also offering to be of help in\n maintaining pt\ns insurance benefit, taking care of her apartment and\n cat and visiting regularly. Health care proxy completed today at the\n bedside, pt appointed her sister as her health care proxy and\n her friend as the alternative. Copy of health care proxy from\n placed on the front of the chart.\n Friends and sisters are talking with pt about where she will live and\n be cared for. Pt somewhat overwhelmed by this at this time but feels\n supported. Pt made aware of the HOSPICE house in should she\n feel that option more appropriate.\n Pt is a private person who does not express emotion or wish to discuss\n thing in depth. Was able to share that she is contemplating not\n perusing chemotherapy tx\ns but states that she will keep her\n appointment for the consultation and listen to the recommendations.\n Will continue to follow pt throughout this admission to support and\n provided concrete services as needed.\n" }, { "category": "Nursing", "chartdate": "2170-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 544729, "text": "Patient is a\n Pleural effusion, acute\n Assessment:\n Patient on 4L N/C, RR 12-20, sats 95-98%, lung sounds clear but\n diminished at the bases; most recent CXR reports slight increase in\n bilateral pleural effusions\n Action:\n Encourage patient to deep breathe/IS; OOB to commode and frequently\n turning in bed independently to maximize lung expansion\n Response:\n Weaned N/C to 3L; continues to report that her breathing relatively\n comfortable, only very slightly winded on activity i.e. getting OOB\n Plan:\n Possibly diurese w/ Lasix later today; thoracentesis for pleural\n effusions on hold for now; continue IS/deep breathing\n" }, { "category": "Nursing", "chartdate": "2170-12-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544631, "text": "Pleural effusion, acute\n Assessment:\n Bilateral effusions\n Action:\n Supplemental oxygen\n Response:\n Adequate SpO2 levels\n Plan:\n Possibly tap effusions today, monitor resp status.\n Pt had settled night, no complaints of nausea, reported headache\n through night, possibly due to diuresis, relieved with Dilauded.\n" }, { "category": "Nursing", "chartdate": "2170-12-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 544192, "text": "Sepsis without organ dysfunction\n Assessment:\n Tmax 99.9. u/o improved. Map >65.\n Action:\n Remains on abx. Ivf changed to maintenance fluid, levo weaned off.\n Response:\n Tol well. Sepsis seems to be improving.\n Plan:\n Con\nt to monitor closely. Follow temp. abx.\n Hypoxemia\n Assessment:\n O2 sat 97% on 4l nc and 40% face tent. Wearing face tent prn for\n comfort. Does desat without it at time. Ls clear, decreased at right\n base. Tachypnea to 30\ns at times but appears comfortable and not\n labored. No sputum\n Action:\n O2 weaned. Pulm hygiene enc.\n Response:\n Improving hypoxemia,\n Plan:\n Con\nt pulm hygiene. Abx for pna.\n Hypotension (not Shock)\n Assessment:\n Map >65.\n Action:\n Levo weaned off this am.\n Response:\n Bp remains stable off pressors.\n Plan:\n Follow closely.\n" }, { "category": "Physician ", "chartdate": "2170-12-19 00:00:00.000", "description": "Intensivist Note", "row_id": 544701, "text": "SICU\n HPI:\n 58yoF with cholangioCa, mets to sigmoid presented with fever 104.0 and\n hypotension to 70s.\n Chief complaint:\n Fever, hypotension\n PMHx:\n Hypothyroidism, R Kidney stones, cholangioCarcinoma- metastatic\n PSH: Knee arthroscopy, ?laparoscopy for ? ovarian cyst,\n Tonsillectmy and adenoidectomy, Colonoscopy many years ago\n Current medications:\n Acetaminophen 3. Furosemide 4. Heparin 5. Influenza Virus Vaccine 6.\n Levothyroxine Sodium 7. MetRONIDAZOLE (FLagyl) 8. OxycoDONE (Immediate\n Release) 9. Pantoprazole 10. Piperacillin-Tazobactam Na 11.\n Prochlorperazine 12. Sodium Chloride 0.9% Flush 13. Ursodiol\n 24 Hour Events:\n Post operative day:\n : reg diet, flagyl switched to PO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 05:26 AM\n Metronidazole - 04:36 PM\n Piperacillin/Tazobactam (Zosyn) - 09:06 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:46 PM\n Heparin Sodium (Prophylaxis) - 09:07 AM\n Other medications:\n Flowsheet Data as of 11:37 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: 37\nC (98.6\n HR: 82 (70 - 105) bpm\n BP: 95/48(59) {92/48(59) - 123/61(72)} mmHg\n RR: 16 (16 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 54.5 kg (admission): 52.3 kg\n CVP: 1 (0 - 3) mmHg\n Total In:\n 1,030 mL\n 827 mL\n PO:\n 300 mL\n 320 mL\n Tube feeding:\n IV Fluid:\n 730 mL\n 507 mL\n Blood products:\n Total out:\n 2,307 mL\n 487 mL\n Urine:\n 2,122 mL\n 487 mL\n NG:\n Stool:\n 185 mL\n Drains:\n Balance:\n -1,277 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilat bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 161 K/uL\n 9.2 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 2.8 mEq/L\n 10 mg/dL\n 104 mEq/L\n 139 mEq/L\n 27.2 %\n 18.3 K/uL\n [image002.jpg]\n 04:07 AM\n 05:13 PM\n 03:15 AM\n 06:02 AM\n 06:46 AM\n 10:47 AM\n 02:02 PM\n 06:23 PM\n 02:02 AM\n 02:13 AM\n WBC\n 39.2\n 18.5\n 19.8\n 18.3\n Hct\n 26.2\n 29\n 25.4\n 30\n 26\n 26.5\n 27.2\n Plt\n 61\n Creatinine\n 0.7\n 0.7\n 0.6\n 0.6\n 0.6\n Troponin T\n 0.06\n 0.06\n 0.06\n TCO2\n 22\n 20\n 19\n Glucose\n 91\n 119\n 113\n 104\n 101\n Other labs: PT / PTT / INR:15.0/26.9/1.3, CK / CK-MB / Troponin\n T:15//0.06, ALT / AST:16/8, Alk-Phos / T bili:224/0.8, Lactic Acid:1.0\n mmol/L, Albumin:2.0 g/dL, LDH:163 IU/L, Ca:7.9 mg/dL, Mg:1.5 mg/dL,\n PO4:3.1 mg/dL\n Microbiology: flagyl switched to PO\n Assessment and Plan\n NAUSEA / VOMITING, PLEURAL EFFUSION, ACUTE, HYPOXEMIA, HYPOTENSION (NOT\n SHOCK), SEPSIS WITHOUT ORGAN DYSFUNCTION, .H/O TACHYCARDIA, OTHER\n Assessment and Plan: 58yoF with cholangioCa, mets to sigmoid presented\n with fever 104.0 and hypotension to 70s.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: No issues currently\n Pulmonary: Nebs PRN; OOB; Wean FiO2\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, replete Potassium\n Hematology: Mod anemia unchanged\n Endocrine: RISS\n Infectious Disease: Cont Zosyn for resistant E.Coli bacteremia\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress), Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 07:48 AM\n 16 Gauge - 08:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\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: 31 minutes\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2170-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046530, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess effusions\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholangioca\n REASON FOR THIS EXAMINATION:\n assess effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:45 AM\n PFI: Pleural effusion decreased and pulmonary edema decreased. Left lower\n lobe alveolar opacity is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP:\n\n REASON FOR EXAM: Cholangiocarcinoma, assess effusion.\n\n Since yesterday, bilateral pleural effusion decreased, now small. Pulmonary\n edema also decreased, with residual interstitial edema. Left lower lobe\n alveolar opacity persists, could be atelectasis, pneumonia or aspiration.\n Right internal jugular catheter ends in unchanged position. Stents are in the\n upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1046016, "text": " 8:03 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a right IJ catheter that extends to the mid portion of the SVC.\n No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1046003, "text": " 5:36 AM\n PORTABLE ABDOMEN Clip # \n Reason: please obtain supine and decub films to assess free air in t\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with abd pain, fever\n REASON FOR THIS EXAMINATION:\n please obtain supine and decub films to assess free air in the abdomen\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal pain and fever, to evaluate for free air.\n\n FINDINGS: Two views show no definite evidence of free intraperitoneal gas.\n However, if this is a serious clinical concern, CT would be recommended.\n\n Residual contrast material in the colon and gallbladder.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1046041, "text": " 12:16 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o intraabdominal or intrathoracic abscess, acute process.\n Admitting Diagnosis: CHOLANGITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholangiocarcinoma, s/p biliary and colonic stent\n placements last week, admitted with septic shock\n REASON FOR THIS EXAMINATION:\n r/o intraabdominal or intrathoracic abscess, acute process. can do PO and IV\n contrast.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with cholangiocarcinoma status post biliary and colonic\n stent placement, now admitted with septic shock. Evaluate for acute process.\n\n TECHNIQUE: 5-mm axial CT scan was obtained from the lung apices to the level\n of the pubic symphysis following the administration of oral and 100 ml of\n Optiray IV contrast. Coronal and sagittal reformatted masses were also\n obtained.\n\n COMPARISON: Chest CT dated and abdomen and pelvis CT dated .\n\n FINDINGS:\n CHEST: There has been interval placement of a right IJ catheter with tip in\n the SVC. An NG tube is also identified with tip in the gastric body.\n\n Small bilateral pleural effusions, which are increased from the prior chest\n CT. The heart and great vessels are unremarkable. There is no mediastinal,\n hilar, or axillary lymphadenopathy.\n\n Lung window images demonstrate increased bilateral lower lobe compressive\n atelectasis. There is also new bilateral posterior upper lobe confluent\n opacities, right greater than left as well as right middle lobe opacification.\n There is mild right apical scarring. There are persistent right upper lobe\n subcentimeter subpleural nodules, which are unchanged from the prior study.\n\n ABDOMEN: Again noted are persistent and relatively unchanged hepatic lesions\n near the dome measuring 1.8 x 3.0 cm and right hepatic lobe measuring 1.2 cm\n in size, which are compatible with metastatic disease. Again seen is a common\n duct biliary stent as well as mild pneumobilia. There also appears to be mild\n intrahepatic biliary ductal dilatation. There is persistent periportal and\n periaortic lymphadenopathy measuring up to 11 mm in maximum short axis. The\n spleen, adrenal and left kidney are unremarkable. There is persistent scarring\n noted in the right kidney. There is also mild prominence of the pancreatic\n duct measuring up to 3 mm. Pancreas is otherwise unremarkable.\n There is a small amount of abdominal ascites. Loops of small bowel are well\n opacified and unremarkable. There is a marked wall thickening noted along the\n ascending right colon compatible with colitis. There is also mild adjacent\n free fluid. The appendix is visualized and appears normal. There is mild\n (Over)\n\n 12:16 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o intraabdominal or intrathoracic abscess, acute process.\n Admitting Diagnosis: CHOLANGITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n irregularity and wall thickening noted along the distal transverse colon and\n splenic flexure also suggestive of colitis. Bone window images are\n unremarkable without lytic or blastic lesions\n\n PELVIS: A rectal stent is identified. A Foley catheter is seen within the\n bladder, which is otherwise unremarkable. There is a small amount of free\n fluid within the pelvis. There is no bulky pelvic lymphadenopathy. Bone\n window images are unremarkable.\n\n IMPRESSION:\n Chest:\n 1. Findings compatible with multifocal pneumonia.\n 2. Increased bilateral effusions as well as bibasilar atelectasis.\n\n Abdomen:\n 1. Persistent and unchanged hepatic lesions compatible with metastatic\n disease.\n 2. Findings compatible with colitis of the right ascending colon as well as\n distal transverse/splenic flexure. ifferential diagnosis includes ischemia.\n 3. Small amount of ascites and free pelvic fluid.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046226, "text": " 5:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?reason for tachypnea\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with tachypnea\n REASON FOR THIS EXAMINATION:\n ?reason for tachypnea\n ______________________________________________________________________________\n WET READ: AKSb SUN 7:55 PM\n Unchanged bibasilar R> L consolidation and small b/l effusions. NGT removed.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 58-year-old woman with tachypnea. Evaluate for etiology of\n tachypnea.\n\n COMPARISON: Multiple prior chest radiographs, most recent from .\n\n FINDINGS: There is an area of consolidation in the right base that is\n unchanged compared to prior radiograph. There are small bilateral pleural\n effusions, unchanged. There is unchanged left basilar atelectasis. A\n nasogastric tube has been removed, but a right-sided central venous catheter\n and billiary stent are unchanged in position. There is no pneumothorax. The\n cardiac silhouette is normal in size and the hilar and mediastinal contours\n appear unremarkable.\n\n IMPRESSION:\n\n Unchanged right basilar area of consolidation, small bilateral pleural\n effusion and left basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046001, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with tachycardia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachycardia.\n\n FINDINGS: In comparison with the study of , there is generalized\n increase in ill-defined pulmonary vessels, especially in the perihilar region.\n This is consistent with elevated pulmonary venous pressure, possibly related\n to overhydration.\n\n No definite pleural effusion or acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046531, "text": ", W. SICU-B 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess effusions\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholangioca\n REASON FOR THIS EXAMINATION:\n assess effusions\n ______________________________________________________________________________\n PFI REPORT\n PFI: Pleural effusion decreased and pulmonary edema decreased. Left lower\n lobe alveolar opacity is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046035, "text": " 11:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Pls verify NGT placement\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman cholangioca, sepsis, s/p NGT placement\n REASON FOR THIS EXAMINATION:\n Pls verify NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube has been placed and extends well into the stomach. In the interim, there\n has been development of some opacification at the right base medially\n consistent with aspiration pneumonia. The descending aorta and medial aspect\n of the left hemidiaphragm were not well seen, suggesting some aspiration at\n the left base as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-15 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1045986, "text": " 3:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval RUQ- h/p cholangitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholangitis\n REASON FOR THIS EXAMINATION:\n eval RUQ- h/p cholangitis\n ______________________________________________________________________________\n WET READ: RSRc SAT 4:05 AM\n No intrahepatic biliary dilatation. Metallic stent in CBD. Trace ascites\n adjacent to liver.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old female with bile duct metastases from a sigmoid colon\n adenocarcinoma. Metallic stent placed for biliary stricture five days ago.\n Having right upper quadrant pain; please evaluate for biliary dilatation.\n\n COMPARISON: ERCP and CT abdomen and pelvis .\n\n RIGHT UPPER QUADRANT ULTRASOUND: Limited imaging of the liver demonstrates no\n evidence of intrahepatic biliary dilatation. Known metastatic disease in the\n segment VIII of the liver is better appreciated on previous CT abdomen\n . A metallic biliary stent is identified. The main portal vein is\n patent, with antegrade flow. The gallbladder is thick walled, but not\n distended.\n\n IMPRESSION: No evidence of biliary dilatation or biliary obstruction.\n Findings posted to the ED dashboard at the time of scanning completion.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1047018, "text": " 11:25 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,37cm and needs tip con\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,37cm and needs tip confirmation please\n page at ,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment of PICC placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the central venous access\n line over the right internal jugular vein has been removed. Simultaneously, a\n right-sided PICC line has been inserted. The tip of the PICC line projects\n over the upper SVC and could be advanced by 3-4 cm.\n\n Although no apical pneumothorax is seen, is visualized. This could be\n indicative of a small basilar fluid of pneumothorax. To either confirm or\n exclude, repeat radiograph should be performed within four to five hours.\n\n Otherwise, the radiograph shows no major change. Mild cardiomegaly,\n retrocardiac atelectasis, bilateral pleural effusions and subsequent basal\n areas of hypoventilation.\n\n The referring physician () was notified by page.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046291, "text": ", R. SICU-B 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? etiology for SOB\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with tachypnea\n REASON FOR THIS EXAMINATION:\n ? etiology for SOB\n ______________________________________________________________________________\n PFI REPORT\n Interval development of pulmonary edema or ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046290, "text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? etiology for SOB\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with tachypnea\n REASON FOR THIS EXAMINATION:\n ? etiology for SOB\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn MON 11:51 AM\n Interval development of pulmonary edema or ARDS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachypnea. Admitted for cholangiocarcinoma and septic shock.\n\n FINDINGS: There has been interval development of multifocal alveolar opacities\n in a slightly perihilar distribution. In addition, bilateral pleural effusions\n have enlarged. Heart size remains unchanged. Right internal jugular, CVL and\n biliary stents are stable.\n\n IMPRESSION: Findings most suggestive of development of pulmonary edema or\n ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1046300, "text": ", R. SICU-B 7:36 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: SOB, DESAT, R/O DVT\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with sob and desaturation\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the right or left lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1046380, "text": " 11:18 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o pulmonary embolism\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with sob and desaturation\n REASON FOR THIS EXAMINATION:\n r/o pulmonary embolism\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb MON 1:45 PM\n No PE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old female with shortness of breath and desaturation. Rule\n out pulmonary embolism.\n\n COMPARISON: Prior study on .\n\n TECHNIQUE: MDCT of the chest was performed before and after administration of\n intravenous contrast. Images were reformatted in the axial, coronal,\n sagittal, and oblique planes.\n\n FINDINGS:\n No filling defect in pulmonary arterial branches suggestive of pulmonary\n embolism.\n Lung window images demonstrate increase in bilateral lower lobe compressive\n atelectasis. There is also worsening of the previously described opacities in\n dependent portions of the upper, middle, and lower lobes bilaterally. Pleural\n effusion has also increased in amount, now moderate on the left and large on\n the right. Previously described subcentimeter subpleural nodules cannot be\n identified at present study, maybe obscured by the consolidation process.\n Heart and great vessels are unremarkable. No enlarged mediastinal or hilar\n lymph nodes according to CT size criteria.\n Evidence of anasarca of abdominal wall soft tissues.\n Limited visualization of abdominal organs demonstrates presence of two biliary\n stents in place. Again seen previously described heterogeneous hypodense\n hepatic lesion near the dome, and small amount of ascites.\n\n Bone windows: Previously described lucency within the left side of the\n vertebral body of L1, seems unchanged since study in .\n\n IMPRESSION:\n 1. Negative examination for pulmonary embolism.\n 2. Worsening of bilateral multifocal consolidations, that could represent\n aspiration or infectious pneumonia.\n 3. Worsening pleural effusions, now moderate on the left and large on the\n right. Adjacent atelectasis with likely coexisting consolidation.\n 4. Anasarca of abdominal wall soft tissues and small amount of ascites.\n 5. Persistent hepatic lesion in the dome, previously described as compatible\n with metastatic cholangiocarcinoma.\n 6. Again seen lucency in vertebral body of L1, of uncertain significance, but\n (Over)\n\n 11:18 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o pulmonary embolism\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n worrisome for metastasis. A bone scan is suggested for further evaluation.\n\n Findings were communicated over the phone to the surgical team at around 17:15\n on .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1046381, "text": ", R. SICU-B 11:18 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o pulmonary embolism\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with sob and desaturation\n REASON FOR THIS EXAMINATION:\n r/o pulmonary embolism\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No PE.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046787, "text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with BL pleural effusions\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 2:15 PM\n Slight increase in bilateral pleural effusions. Stable retrocardiac\n consolidation which may represent a pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 50-year-old woman with bilateral pleural effusions. Evaluate for\n interval change.\n\n COMPARISON: Multiple prior chest radiographs, most recent from .\n\n FINDINGS: The cardiac silhouette is normal in size and the hilar and\n mediastinal contours appear grossly unremarkable. There is slight increase in\n the size of the bilateral pleural effusions. However, there has been interval\n decrease in bilateral pulmonary edema. The retrocardiac density is stable in\n appearance and may represent a pneumonia. A right-sided IJ catheter's tip\n projects over the mid SVC, in unchanged position. There are two radiopaque\n stents projecting over the patient's right lower quadrant which may represent\n biliary stents.\n\n IMPRESSION:\n 1. Slight interval increase in bilateral pleural effusions.\n 2. Interval decrease in pulmonary edema.\n 3. Stable retrocardiac consolidation which may represent pneumonia or\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1046788, "text": ", W. SICU-B 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with BL pleural effusions\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Slight increase in bilateral pleural effusions. Stable retrocardiac\n consolidation which may represent a pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-17 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1046299, "text": " 7:36 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: SOB, DESAT, R/O DVT\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with sob and desaturation\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CLxc MON 12:46 PM\n No evidence of DVT in the right or left lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with shortness of breath and desaturation, rule\n out DVT.\n\n TECHNIQUE: A real-time -scale ultrasound of the bilateral extremities\n from the common femoral veins through the popliteal veins was performed. No\n priors.\n\n FINDINGS:\n\n RIGHT: There is normal compressibility, augmentation, and flow demonstrated\n in the right lower extremity from the right common femoral vein through the\n right popliteal vein.\n\n LEFT: There is normal compressibility, augmentation, and flow demonstrated in\n the left lower extremity from the left common femoral vein through the left\n popliteal vein.\n\n IMPRESSION: No evidence of DVT in the right or left lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1047281, "text": " 1:41 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusion on R, hx pna, remains w/Sp02 requirement\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholgiocarcinoma\n REASON FOR THIS EXAMINATION:\n f/u effusion on R, hx pna, remains w/Sp02 requirement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB FRI 3:59 PM\n PFI: Advancement of PICC with otherwise no change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Oxygen requirement.\n\n FINDINGS: Right PICC has been advanced into the mid superior vena cava. The\n examination is otherwise unchanged from the recent study performed one day\n earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1047282, "text": ", W. FA10 1:41 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusion on R, hx pna, remains w/Sp02 requirement\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cholgiocarcinoma\n REASON FOR THIS EXAMINATION:\n f/u effusion on R, hx pna, remains w/Sp02 requirement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Advancement of PICC with otherwise no change.\n\n\n" }, { "category": "ECG", "chartdate": "2170-12-17 00:00:00.000", "description": "Report", "row_id": 295349, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof except for a slower heart rate.\n\n" }, { "category": "ECG", "chartdate": "2170-12-15 00:00:00.000", "description": "Report", "row_id": 295350, "text": "Sinus tachycardia\nLeftward axis\nLow QRS voltage in limb leads\nSince previous tracing of , sinus tachycardia now present\n\n" } ]

[ { "category": "ECG", "chartdate": "2147-05-25 00:00:00.000", "description": "Report", "row_id": 140486, "text": "Baseline artifact. Probable ventricular tachycardia. The QRS complex is wide.\nThe precordial leads now suggest a right bundle-branch block with broad\nR waves. Since the previous tracing the rate is faster. QRS complex is wider,\naxis has shifted and there is right bundle-branch block. Since the previous\ntracing of ventricular tachycardia is new. Clinical correlation and\nrepeat tracing are suggested.\n\n" }, { "category": "ECG", "chartdate": "2147-05-24 00:00:00.000", "description": "Report", "row_id": 140487, "text": "Normal sinus rhythm. Intraventricular conduction delay. Q waves in\nleads II, III and aVF. Consider prior inferior myocardial infarction. Compared\nto the previous tracing of no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2147-05-24 00:00:00.000", "description": "Report", "row_id": 140488, "text": "Sinus rhythm. Consider inferior myocardial infarction of indeterminate age.\nST-T wave abnormalities with borderline prolonged QTc interval are non-specific\nbut cannot exclude ischemia or drug/electrolyte/metabolic effect. Clinical\ncorrelation is suggested. Since the previous tracing of sinus rhythm\nhas replaced ventricular tachycardia.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2147-05-23 00:00:00.000", "description": "Report", "row_id": 140489, "text": "Regular wide complex tachycardia consistent with ventricular tachycardia.\nSince the previous tracing of the same date wide complex tachycardia is now\npresent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-05-23 00:00:00.000", "description": "Report", "row_id": 140533, "text": "Sinus rhythm. Prominent inferior lead Q waves are non-diagnostic.\nInferolateral T wave changes with borderline prolonged QTc interval. Cannot\nexclude ischemia or possible drug/electrolyte/metabolic effect. Clinical\ncorrelation is suggested. Since the previous tracing of further\nST-T wave changes are suggested but unstable baseline makes comparison\ndifficult.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-05-22 00:00:00.000", "description": "Report", "row_id": 140534, "text": "Sinus bradycardia. Consider inferior myocardial infarction of indeterminate\nage, although is non-diagnostic. Cannot exclude myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of accelerated\nidioventricular rhythm with right bundle-branch block configuration is now\nabsent.\n\n" } ]

[ { "category": "Echo", "chartdate": "2194-03-21 00:00:00.000", "description": "Report", "row_id": 66708, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 145\nBSA (m2): 1.78 m2\nBP (mm Hg): 98/49\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:00\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior -\nakinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic; inferior apex - akinetic; lateral apex - akinetic;\napex - akinetic;\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Mildly dilated aortic root. Moderately dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\n1.The left atrium is normal in size. The left atrium is elongated.\n2. The right atrium is moderately dilated.\n3.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Resting regional wall motion abnormalities include apical,\ninferoseptal, inferor, inferolateral akinesis and anteroseptal hypokinesis.\n4. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is depressed with free wall hypokinesis.\n5.The aortic root is mildly dilated. The ascending aorta is moderately\ndilated.\n6.The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n7.The mitral valve leaflets are structurally normal. Moderate (2+) mitral\nregurgitation is seen.\n8. The estimated pulmonary artery systolic pressure is normal.\n9.There is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , there is a significant decrease in LV function with new LV and RV\nwall motion abnormalities seen. Most notably, there is inferior and\ninferolateral akinesis now seen which was not present previously.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-03-09 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 858021, "text": " 9:46 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: please assess for obstruction. Patient now agreeable to CT s\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with abdominal pain, ventral hernia\n REASON FOR THIS EXAMINATION:\n please assess for obstruction. Patient now agreeable to CT scan. Please see if\n possible to scan ASAP this AM. Got contrast in ED - now most out of NGT. ?Need\n for more contrast. Plz call 9 () if need more contrast.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JLLW SUN 1:01 PM\n SMALL BOWEL OBSTRUCTION, AS DISCUSSED WITH SURGERY.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Abdominal pain, ventral hernia. Evaluate for obstruction.\n\n TECHNIQUE: CT of the abdomen and pelvis were performed after the\n administration of oral and IV contrast. 150 cc of Optiray nonionic contrast\n was given for this examination.\n\n COMPARISONS: CT torso, .\n\n FINDINGS\n\n CT ABDOMEN W/CONTRAST: There are bibasilar atelectatic changes. Visualized\n portions of the heart and pericardium are within normal limits.\n\n The liver, spleen, and adrenal glands are unremarkable. There is a focal\n narrowing of the gallbladder in its mid portion. Lateral low density well-\n circumscribed renal lesions are seen, not significantly changed since ,\n probably representing renal cysts.\n\n There is a large amount of food residua as well as contrast within the\n stomach. The NG tube is only partially into the stomach, and the sideport is\n probably above the gastro-esophageal junction. There is distension of the\n entire intra-abdominal and pelvic small bowel, and contrast only travels\n through the proximal portions of the bowel. Both decompressed distal small\n bowel and right colon are contained by the large right inguinal hernia. There\n is one full loop of distended small bowel extending into this hernia, which\n then exits and continues as more distended small bowel. However, at the\n second entry of small bowel into this hernia sac, a transition point is\n identified. There is free fluid in the right scrotal hernia sac. Within the\n right scrotal hernia sac is nondistended terminal ileum and right colon. The\n entire large bowel is nondistended.\n\n CT PELVIS W/CONTRAST: A Foley catheter is present within the bladder which\n herniates into the left scrotum. There is diverticulosis of the sigmoid\n colon. There is no pelvic lymphadenopathy or free fluid.\n (Over)\n\n 9:46 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: please assess for obstruction. Patient now agreeable to CT s\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n Examination of osseous structures shows no suspicious lytic or blastic\n lesions. There is a marked right-convex scoliosis of the thoracolumbar spine,\n and significant associated degenerative changes of the facet joints.\n\n Coronally and sagittally reformatted images were also reviewed, clearly\n demonstrating the high grade small bowel obstruction described above. In\n addition, scoliosis as well as focal compression fractures at T12 and L2 are\n easily appreciated on these reformatted images.\n\n IMPRESSION\n 1. High grade small bowel obstruction, associated with right inguinal hernia.\n A transition point is seen as a more distal portion of the small bowel re-\n enters this hernia. The distal ileum and colon, enclosed within the right\n scrotal hernia, are decompressed, although there is fluid adjacent to the\n scrotal loops of bowel.\n 2. Diverticulosis.\n 3. Marked scoliosis.\n 4. \"Hourglass\" configuration of gallbladder, likely due to adenomyosis. This\n could be confirmed with ultrasound if clinically warranted.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-03-21 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 859559, "text": " 3:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval placement of NGT\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man ctrl line placement, sbo w/r inguinal hernia repair,\n aspiration pneumonia; now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n please eval placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration pneumonia. NG tube placement.\n\n COMPARISON: .\n\n SEMI UPRIGHT PORTABLE CHEST: NG tube has been positioned with its tip coiled\n in the expected location of the stomach. Increasing moderate to severe\n degree of CHF with more focal left lower lobe opacity as previously described.\n\n IMPRESSION: Satisfactory NG tube placement with worsening CHF.\n\n" }, { "category": "Radiology", "chartdate": "2194-03-22 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 859622, "text": " 4:55 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for ETT placement\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with complicated hospital course, now with hypoxemia and\n pulmonary edema, intubated for hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Complicated hospital course. Assess ET tube placement.\n\n PORTABLE SUPINE AP CHEST, ONE VIEW: Since the prior study of 1 hour earlier,\n the ET tube has been repositioned and now is in satisfactory position with tip\n 3.5 cm above the carina. There is a right IJ line with the tip in the SVC.\n There is an NG tube extending below the diaphragm, tip not visualized. There\n is no pneumothorax.\n\n The left lateral thorax is not included on this exam. There are multifocal\n interstitial and alveolar opacities diffusely, consistent with CHF, although\n appearances are improved from one hour earlier.\n\n" }, { "category": "Radiology", "chartdate": "2194-03-11 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 858293, "text": " 12:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ctrl line placement\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man ctrl line placement, sbo w/r inguinal hernia repair, now in\n afib with rvr\n REASON FOR THIS EXAMINATION:\n ctrl line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 87-year-old with central line placement, status post inguinal\n hernia repair, now in atrial fib.\n\n This study was obtained at 1210 hours and is compared to prior study of the\n same day obtained at 0231 hours. Since the prior study, there has been\n placement of the right IJ line, the tip is in the mid superior vena cava.\n Bilateral pulmonary vascular congestion associated with bilateral pleural\n effusions are noted, most likely indicative of congestive heart failure.\n Cardiomegaly is unchanged. There is associated compression atelectasis of the\n left lower lobe.\n\n IMPRESSION:\n\n 1) Congestive heart failure.\n\n 2) Interval placement of the right IJ line and no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-03-20 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 859400, "text": " 10:51 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate progression/resolution of CHF\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man ctrl line placement, sbo w/r inguinal hernia repair, afib\n with rvr now in nsr, aspiration pneumonia; now with acute SOB s/p diuresis.\n REASON FOR THIS EXAMINATION:\n evaluate progression/resolution of CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement. Small bowel obstruction. Acute shortness\n of breath status post diuresis.\n\n COMPARISON: .\n\n PORTABLE SEMI-UPRIGHT CHEST: There are diffuse bilateral parenchymal\n opacities with pleural effusions and bilateral lower lobe atelectasis with\n cardiomegaly. The appearance of the lungs is improved since the prior study.\n The right central line is in good position and there is no pneumothorax.\n There is significant upper lumbar rightward convex scoliosis with a\n compression fracture noted at that level. Skin staples are present over the\n mid-abdomen.\n\n IMPRESSION: Pulmonary edema slightly improved.\n\n" }, { "category": "Radiology", "chartdate": "2194-03-21 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 859604, "text": " 9:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for infiltrate\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man ctrl line placement, sbo w/r inguinal hernia repair,\n aspiration pneumonia; now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison is made to study of 6 hours earlier.\n There is a right IJ central line with tip in the SVC, unchanged. There is an\n NG tube with a portion of it not visualized, however, the tip projects in the\n region of the stomach. This is also unchanged.\n\n There is no change in appearance of the heart or lungs. There is no\n pneumothorax.\n\n" }, { "category": "ECG", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 145182, "text": "Atrial flutter with 2:1 conduction and ventricular response of about 130.\nCompared to the previous tracing of no diagnostic change with the\nmultiple other abnormalities as noted. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 145183, "text": "Atrial flutter with 2:1 conduction and ventricular response about 126.\nCompared to the previous tracing of ventricular response is now faster.\nInferior Q waves are not noted with shift in QRS axis more vertically, raising\nconsideration of right ventricular overload. Lateral ST-T wave changes are more\nprominent consistent with ischemia, drug effect, etc. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2194-03-21 00:00:00.000", "description": "Report", "row_id": 145184, "text": "Atrial flutter with variable block, average ventricular response about 75.\nProbable prior inferior Q wave myocardial infarction. Possible underlying\nanterior myocardial infarction, given slow R wave progression or R wave\nregression. Possible left ventricular hypertrophy. Non-specific ST-T wave\nchanges which may be due to ischemia, left ventricular hypertrophy, drug\neffect, etc. Compared to the previous tracing of atrial flutter is new,\natrial fibrillation being noted on the previous tracing of . Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2194-03-20 00:00:00.000", "description": "Report", "row_id": 145185, "text": "Sinus rhythm\nConsider inferior infarct - age undetermined\nR wave reversal in leads V2-3 possible old anterior infarct or lead position\nchange\nLateral ST-T changes\nSince previous tracing of , sinus rhythm now present; R wave reversal in\nleads V2-3 of uncertain significance\n\n" }, { "category": "ECG", "chartdate": "2194-03-11 00:00:00.000", "description": "Report", "row_id": 145238, "text": "Atrial fibrillation\nProbable inferior infarct - age undetermined\nST-T changes\nSince previous tracing of , atrial fibrillation new\n\n" }, { "category": "ECG", "chartdate": "2194-03-10 00:00:00.000", "description": "Report", "row_id": 145239, "text": "Probable atrial flutter with 2:1 block. ST-T wave changes may be due to\nmyocardial ischemia. Compared to the previous tracing of the rhythm has\nchanged.\n\n" }, { "category": "ECG", "chartdate": "2194-03-08 00:00:00.000", "description": "Report", "row_id": 145240, "text": "Sinus rhythm\nVentricular premature complex includes couplet\nConsider biatrial abnormality\nPossible prior inferior myocardial infarction - although is nondiagnostic\nModest nonspecific lateral ST-T wave changes\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2194-03-08 00:00:00.000", "description": "Report", "row_id": 145241, "text": "Sinus tachycardia with ventricular premature beats. Left atrial abnormality.\nPossible old inferior myocardial infarction. Compared to the previous tracing\nof the rate is now slower.\n\n" }, { "category": "Nursing/other", "chartdate": "2194-03-11 00:00:00.000", "description": "Report", "row_id": 1299604, "text": "ASSESSMENT AS NOTED\n\nCV:IN A/FIB SINCE 8PM LAST NIGHT, STARTED AMIODORONE GTT + BOLUSES AND ON LOPRESSOR UP TO 10 IV Q4H WITH MODERATE EFFECT. HR DID SLOW DOWN BUT STILL IN A/FIB.80-90S, BP STABLE, ALL LINES ARE PATENT.\nTROPONIN WAS POS X 2 BUT PT DENIES CHEST PAIN OR SOB\n\nRES: UP TO 4L NC, MAINTAINS SO2>95, + PRODUCTIVE COUGHT-YELLOW THICK SM AMNT. LS WITH DIM BASES. 2AM CXR WAS DONE TO R/O CONGESTION-WAS NEG.\n\nGI: NGT WORKS WELL, DRAINS BILE SECRETIONS-100CC, DENIES NAUSEA, ABD SOFT/DISTENDED, DRESSING WAS CHANGED, INCISION INTACT\n\nNEURO: INTACT, GOT MORPHINE PRN , SLEPT ON AND OFF\n\n\nGU: 30-40CC/H, DARK GREEN URINE\n\nPLAN: PULM TOILET, DRAW LAST TROPONIN 1300\n CARDIOVERT IF SBP DOWN\n" }, { "category": "Nursing/other", "chartdate": "2194-03-11 00:00:00.000", "description": "Report", "row_id": 1299605, "text": "PATIENT DOING WELL THIS PM, OOB TO CHAIR TOLERATED WELL X11/2HR. REMAINS IN AFIB , .5MG/MIN AMIODARONE IV PLAN TO KEEP ON THIS DOSE OVERNIGHT IF REMAINS IN AFIB PLAN TO CARDIOVERT IN AM. RIJ TLC PLACED WITHOUT INCIDENT, CVP 6-8, DESPITE LASIX 20MG IV GIVEN AT 1430, ALSO CXR LOOKS WET.. AFIB PERSISTS BUT RESPOND STO LOPRESSOR 10MG IV Q4HRS.. SBP 110-140'S. DOWN TO 2LNP WITH SATS 95% OR BETTER, BILATERAL BS CLEAR USING I/S THIS PM.. GU FAIR U/O 20-30CC/HR AS NOTED LASIX GIVEN THIS PM.. GI NGT DCD, POSTIVE BS/FLATUS PER TRAUMA START ON IC E CHIPS. NO PAIN THIS AM WHILE IN BED OOB TO CHAIR, MEDICATED INTIALLY WITH 2MG MSO4 SC, THEN STILL IN PAIN MEDIACTED WITH 2MG MSO4 IV WITH GOOD RELIEF.. ON HEPARIN SC/VENODYNE BOOTS ON.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-12 00:00:00.000", "description": "Report", "row_id": 1299606, "text": "assessment as noted\n\ncv: remains in a/fib despite of amiodorone and lopressor. planned cardioversion for today.bp stable, slight edema, started on lasix po qd. car enzymes are rising -all 5 sets, ho aware and pt was started on heparin + ecg was done , he denies chest pain all along.\n\nres: ls clear/dim, prod cough, on nc up to 4.5l- for po2 of 62\n\nneuro: intact, turns with assist., cooperative\n\ngi: had some ice chips last night, tolerated well, npo after midnight.\ndenies nausea, abs soft with hypo bs, dressing intact\n\ngu: 40-60/h, amber\n\nheme: hct-37, no obvious signs of bleeding\n\nlines : all lines are intact\n\nplan: cardioversion\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-03-12 00:00:00.000", "description": "Report", "row_id": 1299607, "text": "TSICU NPN (0700-1900)\nEVENTS:\n*** Attempted cardioversion of stable afib this afternoon. NSR for only a few seconds after shock. Back in afib. Continues to be stable. Will continue amio dosing, lopressor, and gentle diuresis.\n\nReview of SYSTEMS:\n\nNeuro....Neurologically intact. No deficits. Denied pain for most of day. Complaining of generalized discomfort this evening. Morphine 2mg given.\n\nCV....Stable afib with HR 90's to low 100's. BP ranging 120-140's/60-70's. Attempted cardioversion with shock x1--did not hold NSR. Plan per cardiology is to continue amio drip until present bag done infusing and then switch to PO if pt tolerates PO. Also continue lopressor and diuresis in hopes pt will convert with these therapies. Pt did rule in for MI. CVP ranging . Weakly palpable peripheral pulses.\n\nRESP...Stable on 3L NC with O2 sats >95%. Afternoon ABG stable compared to am with PO2 of 72. Lung fields generally clear with mildly diminshed bases. Strong cough---occasionally expectorating thick, yellow secretions.\n\nGU....Foley with clear yellow urine seen. Scheduled lasix 30mg PO given this am along with 20mg lasix IV this afternoon. Diuresing well--about even at 1700. Goal was to try for 1L negative. Dr. will readdress need for more lasix this evening. Ca++ and K+ repleted.\n\nGI...Started on CLD post cardioversion. Sipping liquids well, but at times seems to gag. Pt states he is fine and does this at home. Abd softly distended, mildly tender upon palpation. Hypoactive BS. Pt reported +flatus this afternoon. Denies any n/v. Protonix coverage.\n\nHEME....Hepain drip infusing at 1000U/hr with goal PTT 60-80. Noon draw showed PTT of 65. Next due at 1800. Pneumo boots in place.\n\nID...Tmax 97.4. No abx coverage.\n\nENDO...Blood sugars <110.\n\nSKIN...Dry sterile dsg intact to abd incision. Bacside with no breakdown noted.\n\nSOCIAL... brother in for visit. Updated per this nurse and cardiology doctors.\n\nPLAN....Continue amiodoarone--switch to PO if possible. Continue gentle diuresis. Replete lytes accordingly. Pulmonary toilet. CLD--monitor swallowing. Monitor PTT's Q6hrs.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-13 00:00:00.000", "description": "Report", "row_id": 1299608, "text": "Nursing Progress Note.\n\nPlease see CareVue for specifics.\n\nPt condition stable overnight.\n\nHEMODYNAMICALLY:\nMonitoring in A-fib 90s- 105bpm most of night, spontaneously converted to NSR 55-70s with atrial ectopy at 0400hrs. BP stable. Remains on amiodarone infusion- to be changed to oral dosing when bag complete. CVP decreasing with lasix diuresis. Heparin infusion theraputic.\n\nRESP:\nOxygenating well on nasal prongs. Some crackles and exp wheeze Lt base, and some mild exp wheeze on exertion and with conversation. Coughing well and using yankeur suction independently.\n\nNEURO:\nSleeping well post morphine, given per Dr to help with sleep. Otherwise denying pain. PEARL. Fair strength in limbs.\n\nENDOCRINE:\nHas not required coverage per sliding scale.\n\nFLUIDS:\nIV at TKVO. Diuresing well post lasix, goal 1000mL negative.\n\nGI:\nOn clear liquids diet. Taking oral meds and water with some difficulty- having difficulty swallowing pills, and frequently coughing post sips H20. Tolerating ice chips. Pt tried jello but felt he was not tolerating so refuses to have more. Discussed with Dr ? needs speech/swallow eval.\nAbd softly distended, but firm around surgical site. Pt denying pain. Hypoactive bowel sounds present and passing flatus.\n\nID:\nAfebrile.\n\nRENAL:\nDiuresing with lasix.\n\nSKIN:\nIntact. Surgical dressing intact.\n\nSOCIAL:\nNo contact from family overnight.\n\nPLAN:\n? speech and swallow eval.\nOral amiodarone when IV complete.\nGoal PTT 60-80.\nOut of bed to chair if pt tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-19 00:00:00.000", "description": "Report", "row_id": 1299609, "text": "Admit note:\n\nRecieved into from 2 post exacerbation of CHF event. Alert w/labored breathing. On venturi mask + NP. Transfered into bed and connected to monitors. Initial assessment as noted in flow record of Carevue.\n\nROS:\n\nNeuro: Alert oriented x's 3. MAE x's 4. PEARRLA\n\nCV: RSR->SB w/o ectopy. No A fib noted. VSS. Peripheral pulses weak to palpation. On metoprolol 10 mg q/4hr. Dilatzem gtt at 2.5 mg/hr. Amiodorone at 0.5 mg/hr. Heparin gtt at 1200 units/hr, PTT 61 (with in range).\n\nResp: O2 weaned to 6L/ np. Sats 95->98%. No resp distress noted, = rise and fall of chest. Lung sounds clear.\n\nGI: NPO, awaiting video swallow exam. Abd soft w/active BS. Small liquid dark green stool.\n\nGU: Foley patent draining clear yellow urine. Lasix given w/+ response.\n\nEndo: FSG not requiring any coverage.\n\nLabs: K 3.5, awaiting repletion orders for K. Mag 1.9 will replete\n w/K.\n\nSocial: no contact w/family.\n\nPlan: Lyte repletion, diurese, pulmonary toileting, mobilization. ? floor bed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-03-20 00:00:00.000", "description": "Report", "row_id": 1299610, "text": "MICU nursing sdmission note\nPt readmitted MICU after d/c to floor from T-SICU () for CHF. This AM developed labored breathing, RR 30s, CHF exac. Diurresed with lasix 80 mg-> 1700cc urine, 100% NRB and 6L NC. Also started on levo and flagyl for presumed asp PNA. Tx MICU for further management. PMHx - Adm SBO/hernia repair ( ). In SICU, new post-op afib, unsuccessful CV. Pt has been in/out of afib on amiodarone gtt, heparin gtt and dilt gtt. Tx floor and back SICU . Other Hx cardiac cath with stents, CHF, ^chol, HTN, EF 35-40%. See FHP for more data.\n\nIn MICU, Pt cont on dilt gtt, heparin 1250U/hr, amiodarone 5mg/. Dilt titrated 7mg->5mg/hr. Pt has diuresed 2700cc since midnite. CHF consult, pt to be loaded with dig and changed to esmolol gtt and d/c dilt gtt.\n\nNeuro - Pt A&O x 3. MAE, weak but able to Tx bed ->chair with max assist x 2. Denies pain. NPO as pt failed video swallow test. Pt was to have NGT placed in radiology today (not done).\n\nResp - Recieved on 100% NRB and 6L NC. titrated to 60% hi- neb. Sats 93%. RR 26-36, looks slightly labored but is at baseline in hospital per team. Lungs with bibasilar crackles. 12noon lasix held as pt 2700cc neg so far today.\n\nCV - Afib 100s-130s, on dilt and amiodarone gtt as above, also heparin. BP 96-116/43-71. +1 dependednt edema LE. PM lytes sent, K 3.3 to be repleted. Ca repleted on adm. CVP 3.\n\nGI - NPO d/t asp. Was on TPN, ? restart tomorrow. Abd soft, distended. +BS. Abd incision staples intact, slightly pink. Stay sutures intact. OTA.\n\nGU - UOP tapering off 90->35cc/hr. Goal even/-500cc per CHR team.\n\nSocial - Sister and brother in all afternoon, spoke with team.\n\nPlan - Dig load, esmolol gtt, titrate off dilt gtt. Heparin gtt. Monitor I&O. Replete lytes. Pt is full code.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-21 00:00:00.000", "description": "Report", "row_id": 1299611, "text": "7p to 7a Micu Progress Note\n\nOverview of Events - pt with several episodes of sob throughout the night. First episode occurred ~11pm. pt c/o insominia and difficulty breathing. Rales noted at bases. Sats low 90's. Rx with 40 lasix iv and 2 mg ms04 iv. Esmolol drip held for resp distress. Pt's slept for several hrs but awoke ~ 3 am with sob and increased wob. c/o feeling like sputum was stuck in his throat. Ntsx for sm amt thick tan sputum with no improvement. Sats decreased to 71 when sx and returned to 88%. MD notified. ABG taken - 7.46/49/71/9/36 on 95% Hi flow cool neb. 2 L NC added and pt sat in high semi-folwler's position with some improvement - sats 94-96% and pt denied sob.\n\nNeuro - Alert and oriented x 3. MAE. Jerky movements of face and hands noted. No sz activity. Per chart, pt has had tremulousness of tongue/jaw and palate and had ENT eval. md, ? ext tremulousness secondary to esmolol. Pt rx with 25 mg iv benedryl x2 for insomnia with mild effect.\n\nResp - As per above, pt with episodes of sob. LS clear with occas rales at bases, no wheezing noted. RR 25-40. Sats 88-98%. Desats to 70's when o2 removed. Currently maintained on 95% hi flow cool neb and 2 L NC. Dry nonprod cough. Plan is for x-ray early this am.\n\nC-V - HR 89-140 afib with rare pvcs. NBP 100-124/50-65. As per above esmolol held. Diltiazem restarted and currently is infusing at 5mg/hr. Goal is to keep HR < 100. Amiodarone continues to infuse at .5mg/. Pt loaded with .5 iv dig yest and is to receive .125mg iv dig qd. Heparin infusing at 1250 units/hr. PTT 69.9 ( goal 60-80). Hx + troponin leak. Rx with asa qd. No edema noted.\n\nGI - Abd soft and distended. Denies abd pain. +BS. No stool. Abd incision clean, dry and intact. Very mild erythema on incision line. NPO with aspiration precautions. ? restart TPN today vs insertion of ng tube and TF. Hct stable at 34.5.\n\nF/E - TFB neg ~2290ccs. Goal even to 500 neg. U/o fell to 20ccs/hr. Pt rx with lasix per above for sob. diuresed > 200ccs/hr for the next few hrs. Repleted with 40 meq kcl last eve for K 3.3. K 3.1 this am - to be repleted with an additional 40 meq kcl iv. All meds being made in d5w for elevated Na. Na 145 today. BUN 24 Cr 1.0. CVP 1-4.\n\nID - Max temp 99.1 po. WBC 18. Rx with flagyl and levaquin for asp PNA.\n\nSocial - Nephew visited last eve.\n\nA+P - Continue to monitor resp status closely. ? bipap if hypoxia persists. Titrate diltiazem drip to HR < 100. Monitor diuresis and f+e balance - replete lytes prn. Pt will require supplemental nutrition - ? TPN vs TF.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-21 00:00:00.000", "description": "Report", "row_id": 1299612, "text": "MICU nursing progress note 7A-7P\nPt cont on hi- neb 95% with 4L NC. Fragile resp status, desats 68% with mask off for mouth care/Sx. Discussion with MICU team, pt, CHF team and pts PCP Dr . Pt to be Tx with antibx and heart rate control for now. will hold on ETT/CV/SWAN for now.\n\nNeuro - Lethargic, A&O x 3. MAE, very weak. Denies pain. Follows simple commands. Remains on bedrest d/t tenuous resp status. Sleeping on/off naps.\n\nResp - Cont on hi- neb 95%, 4L NC. RR 26-33. Labored breathing pattern but no change from previous exam yesterday. Lungs bil crackles ^. Sats 92-96%, desats to 68% when mask off for oral sx, cleaning. Pt has dry cough with tenacious thick tan oral secretions, requires aggressive mouth care when able d/t high O2. On flagyl/levo for presumed asp PNA. Nebs by RT. Pt requires HOB>45.\n\nCV - BP 90s-100s/30s-60s. Afib 100s-120s on dilt gtt. Also cont Amiodarone 0.5mg/, heparin 1250U/hr, digoxin. Dilt weaned off and esmolol gtt restarted. Pt has converted to ST 100s with occ change to Afib 70s of limited duration on esmolol. EKG done. Esmolol titrated to 50mcg/k/ as BP tolerates. Lasix 40 scheduled dose with diuresis of 540cc urine over 2 hrs. UOP has been 20-60cc/hr otherwise. Pt is 400cc neg so far today. Additional 40 KCL given this AM (=80MeQ for K 3.1). Lytes this PM WNL, x Na 148. +1 LE edema. CVP 6. Echo done pending.\n\nGI - Abd soft, distended. +BS. Retention sutures d/c'd by surgery this AM, Staples remain. Sites under Stay sutures dark purple, ? eccymotic. NGT R nare by HO, placement confirmed by CXR. TF started, Criticare 10 cc/hr, goal 40cc/hr. No stool/flatus.\n\nID - T max 99.5 this AM, has decreased since then. On flagyl/levoflox. Will cx if T spike.\n\nSocial - Pts brother and sister in most of day, talked with PCP and MICU team.\n\nPlan - Monitor resp status, nebs. Mouth care as tolerates d/t resp status. Esmolol gtt, titrate HR<100, BP>90. Cx if T spike. Advance TF as tolerated. Pt is full code.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 1299613, "text": "Respiratory Care\nPt presented on NIV Peep of 5 W ps of 10. BS coarse rhonchi bilaterally. Productive cough, unable to expectorate secretions. At 0400 pt began to decompensate . Increased RR decreased HR and BP.At 0400 Pt intubated W #8 ett advanced to 29 cm at the lip from 23 cm. verified by X-ray.BS rhonchorous, equal bilat. Sx for copious amounts thick yellow green secretions. Please see carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 1299614, "text": "7p to 7a Micu Progress Note\n\nOverview of Events - Pt with worsening hypoxia overnight. Placed on CPAP but eventually required intubation. Hypotensive requiring pressors to support BP.\n\nNeuro - Pt initially alert and oriented but became increasingly restless and agitated while on CPAP. Treated with 2 mg morphine iv with mild effect. Pt required application of upper ext restraints as he attempted to remove 02, iv lines etc. Also sedated with .5mg ativan x 1 - pt slept for one hour and then awoke very agitated - ? effect of medication vs worsening hypoxia. S/p intubation sedation maintained with versed infusing at 2mg/hr and fentanyl at 50mcgs/hr.\n\nResp - As per above, pt placed on CPAP trial which he tolerated for ~ 7 hrs before becoming confused, hypotensive with SBP 60's and tachypneic with RR 40's. Sedated with etomidate and succinylcholine and orally intubated. See careview for Vent setting adjustments and ABGS. Pt currently on AC 500 x 25 10 peep and fio2 80%. LS with scattered rhonchi and rales. Initial chest x-ray last eve showed worsening pulm edema. Rx with a total of 120 mg lasix iv(3 separate doses). 02 sat 88-96 until ~ 3am when unable to obtain sat despite applying probe to ears, forehead and other digits - exts cool - ? pt clamped down. Chest xray this am confirmed ETT placement. Pt sx for copious amts thick green sputum immediately after intubated.\n\nC-V - HR 85-130 afib/aflut. As per above pt hypotensive throought the night. Esmolol and iv ntg dcd. BP currently being supported with dopamine and dobutamine to maintain MAP > 65. Amiodarone continues to infuse at .5 mg/. Pt anticoagulated with heparin, PTT 52.9 - bolused with 200 units and drip increased to 1300 units/hr. Ekg taken this am - no acute changes noted md.\n\nF/E - As per above, pt diuresed with lasix for chf. Diuresed approx 200ccs/hr after receiving lasix but u/o would fall to 20-40ccs/hr in between doses. K 3.1 - repleted with a total of 80 meq kcl iv. K 5.2 this am. Dobutamine currently infusing to improve renal perfusion. Lactic acid 4.9. CVP 6-12.\n\nGI - Abd soft. +BS. Pt NPO and TF dcd as intubation anticipated. No stool. Abd incision clean, dry and intact.\n\nID - Max temp 100 axil. WBC 11. Flagyl and levo dcd. One set BC sent from aline and sputum sample sent. Needs second BC and U/A sent. Plan is for vanco and zosyn.\n\nAccess - RIJ, 2 peripheral ivs RUE, L radial aline. Plan is for cordis and PA cath placement.\n\nSocial - Brother and sister informed of change in pt's condition by MD. Prior to CPAP application pt reiterated that he would want intubation and full resuscitation should the situation require it.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 1299615, "text": "Respiratory Care:\nPt continues to be intubated at this time & ventilated on A/C settings; please see Carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 1299616, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Pt was made cmo at 1600 per wishes of family. Pt is to remain intubated and ventilated only. Morphine drip was initiated at 1600 and at present is at 5mg/hr. Brothers and sister of pt, neice and nephew into visit with pt intermittently throughout shift and after pt made cmo. At present abp has no waveform, pleth for o2 sauration. Af in 90's with occn pvc. Plan is to notify families with significant chabges so they can be present in rm. when pt decompensates.\n\n" }, { "category": "Nursing/other", "chartdate": "2194-03-22 00:00:00.000", "description": "Report", "row_id": 1299617, "text": "Addendum to above nursing progress note.\n Pt passed this life at 1830 hrs, showing no respiratory or cardiac effort. Family at bedside when pt passed. Team notified and pronounced pt deceased at 1840. Care and empathy provided to family. Post mortem care provided. Post mortem refused by family. Pt transferred to morgue by service response. Service response also notified of missing personal belongings that could have been misplaced anytime in the last two weeks.\n" }, { "category": "Nursing/other", "chartdate": "2194-03-10 00:00:00.000", "description": "Report", "row_id": 1299602, "text": "ADM NOTE\n\nPT WAS 1930 LAST NIGHT FROM OR POST EXP. LAP FOR SBO+HERNIA REPAIR\n\nHX: CAD, EF 40, HTN, AR, MR, PTCA, R. HERNIA\n\nWAS IN OR 5 HOURS, STARTED TO UPPER GI BLEED, GASTRIC DECOMPRESSION OF STOOL MIXED WITH BLOOD 2000CC-->RESUSCITETED WITH > 5L FLUIDS-->ICU\n\nRES: REMAINS VENTED, LS CLEAR, VERY SMALL AMNT OF SECRETIONS, GOOD ABGS\n\nCV: SBP REMAINS IN 100 WHILE SEDATED AND UP TO 120 WHEN AWAKE, HAS FREQUENT PVC RUNS(HO AWARE), ON LOPRESOR, NO EDEMA, +PULSES, NO C.LINE WAS PUT IN PER ATTENDING, 2 PIV WORK WELL\n\nGU: OLYGURIC POST OP GOT IVF BOLUSES AND ON IVF 200/H\n\nGI: ABD FIRM/DISTENDED WITH DISTANT BS, NGT INTACT DRAINED AT FIRST BLOODY STOOL AND WAS FLUSHED CONT. ABD DRESSING INTACT\n\nSKIN: FROM OR WITH RED SPOT ON COCCYX\n\nLABS: K, MAG WERE REPLETED, HCT FROM 47 POST OP TO 39 IN AM, INR-1.4\n\nSOCIAL: SISTER CALLED LAST NIGHT AND WAS UPDATED\n\nPLAN: WEAN VENT OFF\n CONSULT CARDIOLOGY\n MONITOR GI, HCT, ???SCOPE\n" }, { "category": "Nursing/other", "chartdate": "2194-03-10 00:00:00.000", "description": "Report", "row_id": 1299603, "text": "Nursing Progress Note\nS/ pt remains alert and oriented MAE to command.\n pt having frequent APC's and , pt then went into AF rate of 130-150 , initially treated with lopressor 5mg x2, rate did not decrease but rhythm converted to NST, another 5mg lopressor X2 given, without effect on rate, Esmolol gtt started at 50 mcg/kg/min without effect on rate, , increased to 100 mcg/kg/min, with decrease in BP and rhythm again AF. Esmolol stopped. and Amiodarone to be started. Pt received Magnesium Sulfate 2 grams.EKG done, lytes WNL\n pt U/O down to 10 cc over 2 hours, 700 cc bolus off LR given with good response to 120cc hr ,U/O now 60 cc hr. IVF at 200 cc hr of LR.\n pt on 2 L nasal canula wqith sats of 99%, RR 18-20 with clear to dininished breath sounds in bases. pt has good spont cough, expectorating thick blood tinged sputum.\nGI- NG to LCS draining brown to bilious draiange , abd is slightly firm, with incisional discomfort, Morphine 2 mg IV given. No bowel sounds\nskin- intact on back and buttucks\nsocial- pt sister in for visit , pt interactive and all questions were answered\nA/ pt cont to have rhythm disturbances, and amiodorane will be started. Cont with plan of care.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1337267, "text": "NSG NOTE\n\nCV: HR 80 AV-PACED. MAPS 66-75. SBP 95-114/47-51. CON'T ON 1MG AMIODARONE. LIDOCAINE OFF PER ORDER OF HO. NO RUNS OF VT/FIRING OF ICD NOTED. CP. HAS HX OF CHF WITH EF30%.\n\nRESP: PASSED WEANING TRIAL. PT @ 2100 TO 40% FM. NOW ON 4L NP. BS DIMINISHED AT BASES. RR-20 O2 SATS 98%. APPEARS OMFORTABLE. RR-REG.\n\nGI: NO STOOL THIS SHIFT. ABD SOFT. HYPOACTIVE BS NOTED. NON TENDER ABD. TOL SIPS OF CL LIQ. ORAL GT D/CD WITH EXTUBATION. GERD ON FAMOTIDINE.\n\nGU: U/O LOW 10-40CC/HR. DR NOTIFIED. PT HAS HX OF CRI. AWAITINT AM BUN/CREAT. BASELINE CREAT 1.7-1.9\n\nSKIN: COCCYX REDDENED WITH SM SKIN TEAR NOTED. .5 X .5CM AREA CLEANED AND DUODERM APPLIED. HEELS REDDENED BUT INTACT. WAFFLE BOOTS APPLIED.\n\nLABS: SERIAL CK 26. MB 5\n\nID: AFEBRILE. NO ACTIVE ISSUES.\n\nNEURO: AROUSABLE TO VOICE. PT ORIENTED TO PERSON. CAN FOLLOW SIMPLE COMMANDS. WILL ASK APPROPRIATE QUESTIONS. LITS AND HOLDS UPPER EXT. LOWER EXT MOVE ON BED.\n\nSOCIAL: HOUSE STAFF SPOKE WITH SON ON REGARDING DISPOSITION ISSUES. PT IS FULL CODE. SON IS AWARE OF TENUOUS SITUATION,STILL PT REMAINS A FULL CODE.\n\nA: GURADED\n\nP: CON'T ON AMIODARONE.\n PER NSG JUDGEMENT\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1337266, "text": "CCU NSG NOTE: V-T\nSEE FHPA FOR COMPLETE ADMISSION INFORMATION\nO: This y old cachetic male was transferred from Rehab today decreasing mental status and episodes of his AICD fireing. In EW he was initially treated for SVT but was proved to have VT treated first with overdrive pacing and at times with shock. He was initally hemodynamically stable, but deteriorated and required intubation and dopamine. He also received 3.5 liters IVF. He was transferred to CCU off dopamine with stable BP.\nCV: Pt was received stable at ~1500. At ~1600 he began to have more episodes of VT with overdrive pacing at times followed by shock. He was loaded with lidocaine at 1645 and started on a 1mg drip. He has not had further episode. By pacer interegation he had 19 total overdrive pacing episodes today and 5 shocks when the overdrive pacing did not convert him to paced rhythm. He is now being A-paced with ventricular response at 80 with rare pvcs. Amiodarone was started at 1715 without a bolus, as he had been bolused in EW. His BP has remained stable in 100-120/40-50s.\nRESP: Pt is intubated on SIMV 50%, rate of 14 with no overbreathing at present, 5 PEEP and 5 PS. He has decreased breath sounds and has been suctioned for thin white secretion. He was initially aggitated and started on propofol. At 1800 propofol was shut off in hopes of extubating patient tonight.\nRENAL: Pt has foley draining clear urine. He is putting out between 10-40cc/hr. He is over 3 liters positive.\nGI: OG tube in place. He had small amt G- food in stomach. No bm\nSKIN: Pt has duoderm over coccyx area that is in tact and has not been taken down. He is very thin (~60 pound weight loss over the past 2 ys)\nMS: Pt was initially aggitated, trashing, but not going for tube. He received 3mg IV versed before being started on propofol. Baseline fuctioning is limited.\nSOCIAL: Pt has adult son who want everything done for his father. seems to have difficulty accepting Mr state and keeps hoping to find and reversible source for his decline.\nA: Elderly male with persistent VT\nP: Wean vent as tolerated. Monitor for further episodes of VT and shocking. Attempt to keep pt comfortable. Support family.\n" }, { "category": "ECG", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 167122, "text": "A-V paced rhythm\nProbable aberrantlt conducted atrial premature complexes\nVentricular premature complex\nSince previous tracing of , ectopy seen\n\n" }, { "category": "ECG", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 167123, "text": "A-V sequentially paced rhythm. Since the previous tracing of there are\nno ventricular premature beats.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 167124, "text": "A-V sequential pacing. Ventricular premature beats. Intraventricular conduction\ndefect. Left ventricular hypertrophy with ST-T wave changes. Since the previous\ntracing of paced rhythm is seen.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 167125, "text": "Probable ventricular tachycardia. Since the previous tracing of no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 167126, "text": "Rapid wide complex tachycardia may be ventricular in origin. Left axis\ndeviation. Anteroseptal and lateral ST-T wave changes suggest myocardial\ninjury/ischemia. Repolarization changes may be partly due to the rate. Since\nthe previous tracing of consider new onset of ventricular tachycardia.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-06-30 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 765347, "text": " 9:21 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 60 y/ with hx of pancreatitis with severe epigastric pai\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with\n REASON FOR THIS EXAMINATION:\n 60 y/ with hx of pancreatitis with severe epigastric pain, tenderness, and\n rlq tenderness\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 y/o man with history of pancreatitis and currently with severe\n epigastric pain.\n\n TECHNIQUE: CT abdomen and pelvis with and without IV contrast and with oral\n contrast. 150 cc of optiray contrast was used. Non ionic contrast was used\n secondary to patient's debility.\n\n COMPARISON: \n\n CT ABDOMEN WITH AND WITHOUT IV CONTRAST: The lung bases demonstrate bilateral\n small pleural effusions. There liver has diffuse fatty infiltration. The\n gallbladder is unremarkable. The pancreas is well visualized and demonstrates\n peripancreatic inflammation. The degree of inflammation is consistent with\n severe pancreatitis. There is no evidence of pancreatic necrosis. There is\n no evidence of pancreatic cyst. The spleen is unremarkable. There is once\n again noted is a left adrenal mass. This is unchanged in size. Both kidneys\n enhance and excrete contrast symmetrically and uniformely. There is a right\n renal cyst. The stomach, small bowel, and large bowel are all unremarkable.\n There is no significant retroperitoneal lymph node enlargement.\n\n CT PELVIS WITH IV CONTRAST: The distal ureters, bladder and rectum are all\n unremarkable. There is no free fluid, no free air, and no abnormal lymph node\n enlargement within the pelvis. The bones demonstrate no suspicious lytic or\n sclerotic lesions.\n\n IMPRESSION:\n 1) Severe pancreatitis. No evidence of cyst, mass, or pancreatic necrosis.\n 2) Fatty liver.\n 3) Adrenal mass on the left, unchanged since prior exam.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-06-30 00:00:00.000", "description": "Report", "row_id": 1519530, "text": "NPN admit note\nPt admitted from ED after presenting with severe abd pain .CT scan showed Pancreatitis. Pt was treated with NSS IVF and mso4 for pain(for more details see admit note.)\n\nNEURO; AXOX3, MAE, presently rates pain as .Ordered for PRN MSO4\n\nC/V: HRR no ectopy,BP stable, no edema.\n\nRESP: LCTA sats 98-100% on 2liters.Denies cough or SOB.\n\nGI: Large firm obese abd, pos BS, s last BM last noc,normal.NPO for pancreatitis.\n\nGU: Foley cath draining clear yellow urine 50-75cc hr\n\nSkin: W/D/I\n\nF/E/N: NSS @ 100cc/hr, Mag /K+ /Ca+ repleted in ED. Recheck labs @ 2200 and AM.\n\nEndocrine: Pt with triglycerides @ 5100,BS 299 started on insulin Gtt @ 1800 @ 2units an hr.On hourly FS,w /gtt SS coverage.No S/S hyper or hypoglycemia.\n\nPlan:Hydration,maintain BS 80-120,pain management.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-01 00:00:00.000", "description": "Report", "row_id": 1519531, "text": "rn progress note\n 7am\nneuro: aox3 very pleasant. c.o pain with moving does not tolerate lying on right side per patient. morphine given in 2mg doses fvery effective in controlling pain.\nresp no issues ls clear.\ngi: c/o belly pain sporadically lower abd area.\ngu: uo >30cc/hr\nendo: bs 270-170 ins. gtt at 14u/hr at this time\nlabs pending.\nplan: cont to monitor bs tirtrate ins gtt as needed., moniotr labs, and vs.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-01 00:00:00.000", "description": "Report", "row_id": 1519532, "text": "Pain\nD: pt. c/o constant abdominal pain without precepitating activity, positioning. NPO. RR in 20's. HR ST in low 100's. Blood glucose decreasing. u/o low after maint IV of 2L finished\nA:medicated prn (~q2h) with IVP Morphine\nMorphine PCA started\ndiet advanced to clears\nNS bolus x 500 ml\nCa repleted\nK phos infusing @ 41 ml/hr (to infuse over 6 hours)\nInsulin gtt titrated\nMaint IV changed to NS with 20 meq KCL @ 200/hr\nR: u/o slowly improving after bolus but HR con't to be tachy. Pt subjectively offering that pain is becoming much better and explained use of PCA. Labs to be repeated @ 1600\n" }, { "category": "ECG", "chartdate": "2101-06-30 00:00:00.000", "description": "Report", "row_id": 297275, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2139-08-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1251103, "text": " 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 77F with epigastric pain and new EKG changes\n REASON FOR THIS EXAMINATION:\n eval for ptx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Epigastric pain and EKG changes.\n\n TECHNIQUE: Upright AP and lateral views of the chest.\n\n COMPARISON: CT torso and chest radiograph .\n\n FINDINGS:\n\n Moderate enlargement of cardiac silhouette is unchanged. The mediastinal and\n hilar contours are stable, with calcification of the aortic knob again\n present. Lungs are clear and the pulmonary vascularity is normal. No pleural\n effusion or pneumothorax is visualized. Cholecystectomy clips are seen in the\n right upper quadrant of the abdomen.\n\n IMPRESSION:\n\n No acute cardiopulmonary abnormality.\n\n DFDdp\n\n" }, { "category": "ECG", "chartdate": "2139-08-16 00:00:00.000", "description": "Report", "row_id": 271101, "text": "Sinus rhythm. Occasional premature atrial contractions. P-R interval\nprolongation. Compared to the previous tracing of there is no\nsignificant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2139-08-16 00:00:00.000", "description": "Report", "row_id": 271102, "text": "Sinus bradycardia with sinus arrhythmia and baseline artifact and borderline\nfirst degree A-V conduction delay. Compared to tracing #1 of Mobitz\ntype II block appears to be absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2139-08-14 00:00:00.000", "description": "Report", "row_id": 271103, "text": "Sinus bradycardia with probable second degree Mobitz type II block. No\nprevious tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2106-08-30 00:00:00.000", "description": "Report", "row_id": 235662, "text": "Atrial fibrillation with rapid ventricular response and occasional ventricular\nectopy. Consider prior inferior myocardial infarction. Compared to the previous\ntracing of there is occasional ventricular ectopy. Otherwise, no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2106-08-31 00:00:00.000", "description": "Report", "row_id": 235660, "text": "Sinus rhythm. Left atrial abnormality. Consider prior inferior myocardial\ninfarction. Compared to the previous tracing of atrial ectopy is absent.\nOtherwise, no diagnostic interim change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2106-08-31 00:00:00.000", "description": "Report", "row_id": 235661, "text": "Sinus rhythm and occasional atrial ectopy. Compared to the previous tracing\nof sinus rhythm and occasional atrial ectopy have appeared.\nTRACING #2\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2195-11-20 00:00:00.000", "description": "Report", "row_id": 1788728, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get 61cc\nq4h po/pg. Infant bottledx1 so far this shift. Abdomen is\nbenign, given glycerin supp. this afternoon. Infant voiding.\nNo spits, aspirates. On Diuril and Kcl supps. A:\nTolerating feeds. P: Enocurage po feeds.\n\n#4 DEV S/O Infant in , maintaining temps. Becoming more\n and active with cares. Sucking on pacifier. Waking\noccasionally for feeds. A: AGA P: Continue to support dev.\n\n#5 Parenting S/O: Mom called this am. Checking infants\nweight, how much she ate. Asking questions. A: Involved,\nloving. P: Continue to support and update.\n\n#8 RESP/CV S/O: Infant in NC 500cc, 40-55%. Infants lungs\nare clear, improving upper airway congestion. RR 30-60's. No\nspells. HR 140's, BP stable. A: Infant stable in NC. P:\nContinue to support and monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-21 00:00:00.000", "description": "Report", "row_id": 1788729, "text": "NPN 11p-7a\n\n\n#2: TF restricted at 130cc/kg/d of BM30w/PM. Infant feeding\nPO/PG, please see flow sheet. abdomen is benign, voiding and\n. No spits or aspirates. A: Tolerating feeds. P:\ncont with plan.\n#4: Temp stable in open air crib, fontanelles are soft and\nflat. and active with cares, sleeping well. Irritable\nat times. A: AGA. P: cont to support.\n#5: NO contact at this writing.\n#8: conts in 500cc/45-55% all shift to maintain O2 sats. RR\n40-50s, clear and equal with UAC noted. COlor is and\nwell perfused, no spells. A: Stable. P: Cont to monitor.\n#9: HR140-150s, and well perfused. Cap refill brisk,\npulses normal. Attempted BP x3 but unable to obtain due to\npatient irritability. A: Stable. P: cont to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-04 00:00:00.000", "description": "Report", "row_id": 1788791, "text": "NPN 0700-1900\n\n\n#2 O: TF= 130cc/kg/d. Infant taking 80,80 and 45cc's of BM24\nafter a breastfeeding session this shift. Abdomen benign;\nvoiding and . No spits. On iron as ordered. A:\nTolerating feeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in . Awake and with cares;\nsleeping well between. Placed in swing for a little while\ntoday. Waking on own for feeds. Needs repeat car seat test\ntonight. A: AGA. P: Cont to support development.\n\n#5 O: Both in to visit for 1700 cares. Independent\nwith cares; mom independent with breastfeeding. Mom needs to\nhave med administration taught to her. Anxious for d/c day.\nA: Involved. P: Cont to support and update.\n\n#8 O: Infant remains in RA. O2 sats 91-97%. RR 30's-60's. LS\nclear and =; some upper airway congestion noted. No spells.\nOn diuril and kcl as ordered. Infant now day for\nbradycountdown. Last brady was on ; infant has been\nnoted to choke since then while bottle feeding. A: Stable in\nNC o2. P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-28 00:00:00.000", "description": "Report", "row_id": 1788497, "text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\nbetween 90-96%. Lung sounds clear/=. RR 40-60's. IC/SCR\nnoted. No spells noted thus far. Occ drifts to mid 80's\nnoted - QSR. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 100 cc/kg/day. IV fluids are currently\nat 65 cc/kg/day of D10w with 2 mEQ of NaCl (fluids will be\nchanged to PND10 and IL at 1800) running through a patent\nPIV without incidence. Ent feedings are currently at 35\ncc/kg of PE20, advancing by 15 cc/kg/. Tolerating NGT\nfeedings well; abd exam benign, no spits, AG stable. Asp\nhave been 0.8-1.0, yellow - team aware. UO for past 8 hours\nhas been 2.0 cc/kg/hr. Sm amt of trace stool noted. P:\nCont. to support nutritional needs and check lytes in am.\n\n3. I/D: CBC benign, BC pending. No overt s/s of infection\nnoted. P: Cont. to follow BC and monitor for s/s of\ninfection.\n\n4. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P: Cont.\nto support developmental needs.\n\n5. Parents: was in to visit x 1. He was updated on\ninfant's condition and plan of care. Asking appropriate\nquestions. Mother is still upstairs in L&D with unstable\nB/Ps. Loving, involved parents. P: Cont. to support and\nupdate parents.\n\n6. Bili: Infant was started under single phototherapy at\n0930 with eye shields in place. Infant is ruddy/jaundiced.\nbili this am was 6.0/0.2. P: Check a bili level in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-28 00:00:00.000", "description": "Report", "row_id": 1788498, "text": "Fellow note: physical exam\nAlert, active. RA. Under phototharapy. RRR S1S2 nl No murmurs. Femorals palpable. Mild I/C and S/C retractions.CTAB soft, NTND BS hypoactive. AFOF Tone and power AGA MAEW CR< 2 secs\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788499, "text": "NPN NOCS\n\n\n1. O: Remains in RA. LS clear. O2 sats 91-97%. No drifts. No\nspells. RR 30-70's. A: Stable. P: Continue to monitor.\n\n2. O: Wt 1285, down 25gms. TF remain at 100cc/kg. Feeding\nadvaced to 50cc/kg of PE20- gavaged over 20min. IVF PN and\nlipids infusing well. Abd benign. No residual. No spits.\nVoiding and stooling. Lytes and glucose drawn and pending.\nA: Tol advacing feeds. P: Continue with plan. F/U with lab\nresults.\n\n3. O: VSS. Blood cx remains neg to date. A: No s/s of\ninfections/sepsis. P: F/U with lab results.\n\n4. O: Temp stable in servo isolette. Alert and active with\ncares. Boundaries in place. A: AGA. P: Continue to support\ndev needs.\n\n5. No contact from thus far this shift.\n\nBili: Remains under single phototherapy as ordered.\nJaundice. Bili drawn and pending. A: Hyperbili. P: Continue\nwith plan. F/U with labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788500, "text": "6 hyperbili\n\nREVISIONS TO PATHWAY:\n\n 6 hyperbili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-27 00:00:00.000", "description": "Report", "row_id": 1788623, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=150cc/kg/day of BM 28w/PM. PO 1X shift,\ntaking only 20cc, remainder gavaged. Mom put inf to breast,\npoor BF session. gavage feedings well. No spits, \nasp. Belly soft, no loops. Inf voiding, trace stools thus\nfar. P cont to assess FEN needs.\n4. DEV O/A Temp stable in . A/A w/cares. Sleeps well\nbetween cares. P cont to assess dev needs.\n5. O/A Mom in for visit and cares. Independent\nwith care of infant. Updates given. P cont to support,\neudcate.\n8. Resp O/A rec'd inf in NC. Inf remains in NC 100-125cc\n100% thus far. No spells thus far. P cont to assess resp\nneeds.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-04 00:00:00.000", "description": "Report", "row_id": 1788661, "text": "NPN \n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 50cc q4h pg. To be bottled once a shift. Infant\nbreast fed today. Abdomen is benign, voiding and .\nNo spits, minimal aspirates. On KCL supps, Vit E and Iron.\nTo have nutrition and lytes tomm. A: Stable P: Continue\nto encourage po feeds.\n\n#4 DEV S/O: Infant in maintaining temps. with\ncares, sleepy in between. Sucking on pacifier. A: AGA P:\nContinue to support dev.\n\n#5 Parenting S/O: Mom in today for 1300 cares. Changed\ndiaper and took temp. Mom breast fed and had lactation\nconsultant appointment. Mom asking appropriate questions. A:\nInvolved, loving P: Continue to support.\n\n#8 RESP/CV S/O: Infant remains in NC 500cc, 55-75% FIO2.\nLungs are clear, rr 50-90's . O2 sats 88-98%, no spells. HR\n150's, BP 64/30/44. Infant appears pale/. Has audible\nmurmer. A: Stable in NC. P: Continue to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-05 00:00:00.000", "description": "Report", "row_id": 1788662, "text": "2. F/N: O: Infant is on 130cc/k/d of BM30 + promod, q 4 hour\nfeeds. She bottled the first feed at 9p very well w/ the\nyellow nipple. She has been gavaged the rest of the feeds\nover 50 . Abd is benign, she is voiding, no stool so far\nthis shift. No spits. She gained 60g. Nutrition were\nsent. A: feeds, learning to bottle. P: Monitor. Continue\nw/ plan.\n\n4. G/d: O: Temp is stable in the open crib. Infant is \nand active w/ cares and sleeps well inbetween. A/P: Continue\nto support infant needs.\n\n5. : O: Mom called for an update and was pleased that\n took her whole bottle. A: Loving, involved Mom. P:\nContinue to support.\n\n8. Resp: O: Infant is on a nc, 500cc flow and in 55-70%\nFiO2. RR 50-70s. She was sxned for two large nasal plugs at\nthe first care time. No spells. She does drift in her sats\nbut also does a lot of grunting and bearing down during\nfeeds trying to stool. A: Needing O2 via nc. Needing\noccasional nasal sxning. P: Continue to monitor. Wean as\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-05 00:00:00.000", "description": "Report", "row_id": 1788792, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF 130cc/k/d. Infant to get bm24, 69cc q4h po.\nInfant bottled 110, and 65cc so far this shift. Abdomen is\nbenign, voiding and . Getting prune juice . No\nspits. A: Tolerating feeds. P: Continue to support.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive, waking 3-4 hrs. Infant passed carseat test tonight.\nA: AGA P: Continue to support dev.\n\n#5 Parenting S/O: Mom called tonight for updates. Asking\nabout wt and how much infant bottled. States she will be in\n. A: Involved, loving P: Continue to support and\nupdate.\n\n#8 Resp S/O: Infant in RA. O2 sats 88-97% tonight. No\nspells, occasional drifts into mid 80's. Lungs are clear,\nmild subcostal retractions. RR 40-60's. A: Stable P:\nContinue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-05 00:00:00.000", "description": "Report", "row_id": 1788793, "text": "Neonatology Attending\nDOL 69\n\nRemains in room air with no distress and no apneas/bradycardias (now day of 5-day apnea watch). On diruil.\n\nNo murmur. BP 82/44 (62).\n\nWt 3195 (+30) on TFI 130 cc/kg/day BM24, with intake 140 cc/kg/day in the past 24 hours. Voiding and normally.\n\nTemperature stable in open crib. Repeat car seat testing passed.\n\nA&P\n31-4/7 week GA infant with resolving respiratory immaturity\n-We will confirm date and time of most recent apnea/bradycardia to guide decision regarding discharge timing\n-Otherwise continue current management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2195-12-05 00:00:00.000", "description": "Report", "row_id": 1788794, "text": "Neonatology- Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, toleraitng feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-05 00:00:00.000", "description": "Report", "row_id": 1788526, "text": "NPN 1900-0700\n\n\n#2Nutrition. Wt. 1365 gms, up 50 gms. BW 1370 gms. Pt. on TF\nof 150cc/k/day of BM24, 34cc being gavaged over 45 minutes\nq4hrs. Pt. noted to have soft transient loops with 2100 care\ntonight, transient soft loops present but decreased at 0100\ncare. Abd. full, soft, , active BS.Girth 21.5. Pt. had\nheme neg trace stool x1, then had heme positive green stool\nx1.Fissure noted on exam. Maximum aspirate .8cc, bilious\ncolor to partially digested BM, NNP aware, examined pt. at\nfirst 2 cares tonight. A: Soft loops present. P: Continue to\neval. abd. exam, repeat KUB if indicated. Monitor for\ntolerance of feeds.\n\n#4Dev. Pt. nested on sheepskin in servo control isolette,\nmaintaining temp. Pt. alert and active with cares, settles\nwell between cares. MAE, AFF. Not interested in pacifier\novernight, putting hands to face. A: AGA. P: Support\ndevelopmental needs.\n\n#5Parents. No contact with so far tonight.\n\n#6Bili. Pt. continues under single phototherapy with\neyeshields in place. Color ruddy. P: Continued phototherapy.\n\n#7 Potential sepsis. Pt. no longer on antibiotics. Pt. well\nperfused, BP 46/38, MAP 41. Pt. continues with drainage from\nleft eye. No increasing signs of sepsis noted. Plan to\ncontinue to monitor for signs of sepsis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-05 00:00:00.000", "description": "Report", "row_id": 1788527, "text": "Neonatology\nDOing well. REmains in RA. Spells not problem.\n\nWt 1365 up 50. TF at 150 cc/k/d. Abdomen with soft loops last night.\nCOntinuing with feeds given normal apeparance this am.\n\nAbx dced yesterday afetr repeat BC was negtive. EXpect initial CNS recovery was contaminant.\n\nBili in range yesterday under phototherapy. Will dc and follow.\n\nHUS for am.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-05 00:00:00.000", "description": "Report", "row_id": 1788528, "text": "Nursing NICU Note\n\n7 Infant with Potential Sepsis\n\n#2. FEN O: TF 150cc/kg/d of BM24 =34cc Q 4hrs, gavaged\nover 45 min, tolerated well. Abdomen is soft, , +BS, no\nloops/spits noted. Abdominal girth is 21cm. She is\nvoiding/ stooling guiac - stool x2. A: Pt. is tolerating\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance.\n\n#4. Growth/Development O: Pt. remains in a\nservo-controlled isolette, nested w/ stable temps. She is\nalert and active w/ cares, sleeps well in between.\nFontanelle soft/flat. She uses her pacifier on occasion.\nA: AGA P: Continue to provide environment appropriate for\ngrowth and development. HUS scheduled for Tuesday.\n\n#5. O: in to visit this morning. He was\nupdated at bedside on pt's current status and daily plan of\ncare. asking appropriate questions, participateing in\ncares well. A: Family loving and involved. P: Continue\nto update, support and educate.\n\n#6. Hyperbilli O: Pt. remains slightly ruddy, warm and\nwell perfused. Photo therapy D/C'd this am. A: Problem\nresolved. P: Plan to check on Wednesday.\n\nREVISIONS TO PATHWAY:\n\n 7 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-05 00:00:00.000", "description": "Report", "row_id": 1788529, "text": "6 hyperbili\n\nREVISIONS TO PATHWAY:\n\n 6 hyperbili; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-05 00:00:00.000", "description": "Report", "row_id": 1788530, "text": "Fellow note: physical exam\nAlert, active. RRR S1S2 nl No murmurs. Femorals palpable. MIld retractions. CTAB. full, soft, NTND BS actice. MAEW CR< 2 secs\n" }, { "category": "Nursing/other", "chartdate": "2195-10-14 00:00:00.000", "description": "Report", "row_id": 1788569, "text": "npn addendum\nagree with above pca note.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-05 00:00:00.000", "description": "Report", "row_id": 1788663, "text": "Neonatology Attending Note\nDay 39\nCGA 37 2\n\nNC 500cc, 55-70%. RR60-80s. Cl and =, +sc rtxns. HR 150-160s. +murmur. BP 79/34, 50.\n\nWt 2350, up 60 gms. TF 130 cc/k/day BM30 w promod po/pg. po attempts much better. Nl voiding and .\n\n137/5/100/32/10.\nCa 10.6, P 6.9, Alb 3.4\n\nIn open crib.\n\nA/P:\n - Increasing to hi-flow O2 system has improved clinical status. She is much more tolerant of feeding, handling and has improved activity. Will con't hi-flow system and wean gradually. Remains on fluid restriction and further diuretics is currently on hold.\n - No change to nutritional plan. Electrolytes gradually improving with KCL supplementation. Con't to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-05 00:00:00.000", "description": "Report", "row_id": 1788664, "text": "Neonatology- Physical Exam\n\n remains on NC 500cc. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. No murmur audible, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-15 00:00:00.000", "description": "Report", "row_id": 1788708, "text": "NPN 0700-1900\n\n\n2.FEN: Infant remains on TF 130cc/kg/day of BM 30cal/oz\nwith promod. Infant was bottled overnight and showed\nincreased work of breathing this morning. Infant has been\ngavaged q feed today. Infant is tolerating feedw well with\nmax aspirate 3.0 cc and one small spit. Abdomen is round and\nsoft with consistent abdominal girths. Infant is voiding\nand has had 2 trace green stools this morning. Infant\nappears to be pushing to stool without production.\nGlycerine suppository given. Infant is recieving Fe+,\nvitamin E, and KCl- supplemements in addition to Diuril.\nElectrolytes done this morning, unremarkable. Continue to\nmonitor FEN status.\n\n4.DEV: Infant is swaddled in an open crib with stable\ntemps. She is and active with cares, sleepy at times,\nand sleeps quietly between cares. She sucks vigorously on\npacifier and brings hands to face. Continue to support\ngrowth and development.\n\n5.Parenting: Mom in to visit yesterday, plans to visit\ntomorrow (Monday). No contact thus far this shift.\nContinue to support and keep informed.\n\n8.Resp: Infant remains on NC 500cc, 60-70% Fi02. Lung\nsounds are clear and equal with upper airwary congestion.\nRRs today 50s-70s with 02 sats 92-97%. She has occasional\ndrifts to the low-mid 80s that are quickly self-resolved.\nNo spells thus far this shift. Infant remains on Diuril.\nContinue to monitor respiratory status.\n\n9.CV: Infant has a soft intermittent murmur. She is pale\n and well perfused with HRs 150s-160s. BP today\n76/42(52). Continue to monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-20 00:00:00.000", "description": "Report", "row_id": 1788594, "text": "NPN 7a-7p\n\n\n#2: conts on TF: 150cc/k/d. Feeding Bm28 with\nPromod, 46cc q4hrs gavaged over 40mins. Sm spit x1. \nbenign asps. Abd soft, +, no loops. Attempted to\nbreastfeed x1 today. Per Mom infant did latch and take few\nsucks, but infant's mouth is very small in comparison to\nMom's nipple. Infant was able to open and get a majority of\nnipple in mouth, but not all. Voiding qs. Stooled x2, heme\nnegative. A: 'ing full feeds P:Cont to follow wt and\nexam. Monitor to feeds.\n\n#4: conts to maintain stable temps while swaddled in\nan OAC. Alert and active with cares. Settles easily with\ncontainment, and sleeps well in btw cares. Will suck on\npacifier intermittently. MAE. Fonts soft/flat. A: AGA\nP:Cont to support dev needs.\n\n#5: Mom in for afternoon feed. Indep with care. Update\ngiven. Mom attempted to breastfeed. Assisted her with\ndifferent positions for feeding. Scheduled LC appt for\nFriday at 1300. A: Involved, loving parent P:Cont to\nsupport and educate.\n\n#8: remains in NC 100%, 50-125ccflow. Has needed ^\nto max of 200cc flow for cares, and breastfeeding. Breathes\neasiest in prone position. BBS cl/=. Sx'ed x1 for sm amt\nwhite secretions. Conts with mild intermittent tachypnea,\nRR generally 50-80, occ as high as 100. \naware. No ^'ed WOB noted. No apnea/brady spells noted thus\nfar. A: Flucuating O2 req P:Cont to monitor and provide\nsupport as needed. Caffiene d/c'ed as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-21 00:00:00.000", "description": "Report", "row_id": 1788595, "text": "NPN\n\n\n#2FEN:\nO: Wt 1.865(+25 gms) On 150cc/k/d BM 28 with pro. Abd, soft,\nactive BS. No asp or spits. gavages well. voiding qs,\n G-\nA/P; Cont. with plan\n\n#4Dev:\no: temps stable in open crib, MAE. AFSOF. alert and active\nwith cares.\nA/P: Cont to support dev.\n\n#5Parenting:\no: No contact at this time\n\n#8resp:\no: Remains in cannula 100% 200cc with cares and activity,\nweans to 75cc at rest. RR 60-80, mod IC/SC retractions.\nSx'ed small blood tinged. Sats kept in mid 90's.. No bradys\nnoted.\nA/P: Cont to monitor for increased WOB and FIO2 requirement.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-21 00:00:00.000", "description": "Report", "row_id": 1788596, "text": "Neonatology Attending Note\nDay 24\n\nNC 50-100cc, inc w feedings. RR 60-90s (baseline). Mild sc retrxns. HR 130-170s. BP 61/34, 48.\n\nWt 1865, up 25. TF 150 cc/k/day BM28 w promod. Mostly pg. On Fe and Vit E.\n\nIn open crib.\n\nA/P:\ngrowing preterm infant with resolving lung dz, immature feeding skills. No change to current management plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-21 00:00:00.000", "description": "Report", "row_id": 1788597, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal.nl S1S2, no audible murmur. and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exma.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 1788635, "text": "Neonatology Attending Note\nDay 32\n\nNC 100-200cc, 100%. Inc w handling. RR50-80s. +desats. +UA congestion. Mild rtxns. BP 82/44, 56. +murmur (cardiac eval negative). HR 150-180s.\n\nWt 2205, up 50 gms. TF 130 cc/k/day BM30 w promod. Alt po/pg. well. Nl voiding and .\n\nIn open crib.\n\nA/P:\nContinues w/ moderate O2 need. Fluid restriction may not be addking any benefit however, is growing well.\n\nWill check another CXR today to monitor for any changes.\n\nNo change to nutritional plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-27 00:00:00.000", "description": "Report", "row_id": 1788491, "text": "Admission Note\n1370 gram infant female delivered at 31 4/7 weeks by C/S to a 35 yo G2P1-2 A+/Ab neg/RPR NR/RI/HepBsAg neg/GBS unknown/ mother with an of .\n\nPregnancy complicated by PIH treated with MagSO4.\n\nMother is Beta complete as of .\n\nInfant delivered from transverse position by C/S and brought to radiant warmer. Infant bulb suctioned/dried/stimulated with good response. Infant remained slightly hypotonic and received approx 10 seconds of PPV.\n\nApgar scores 7 and 7 at 1 and 5 minutes\n\nPE:\n\nWeight: 1370 grams\nLength: 16 in or 40.5 cm\nHC: 27 1/4 cm\n\nNon dysmorphic newborn infant\nNCAT, AF open/flat/soft\nRRR no m\nClear but diminished BS\nSoft abdomen + BS no HSM\nnl preemie female GU\n+ 2 pulses\nnonfocal neuro exam, but mildly hypotonic\nskin clear\n\nA/ Preterm infant female delivered at 31 4/7 weeks gestation for maternal indications\n\nP/\n\nResp: Will follow for evidence of apnea in light of maternal MgSo4. Will evaluate as clinically indicated for evidence of RDS\n\nCVR: Stable BP's, follow for evidence of PDA\n\nID: Will send CBC, diff, platelets in light of hx of maternal pre-eclampsia to evaluate for evidence of bone marrow suppression. No clinical indication at this time for initiation of antibiotics\n\nNeuro: Hypotonia likely secondary to maternal MgSo4\n\nFEN: Will place IV and initiate feeds when clinically appropriate.\n\nSocial: Parents updated in OR.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-27 00:00:00.000", "description": "Report", "row_id": 1788492, "text": "Admission Note\n0725 admit note 31 week female infant delivered via c/s(see above note for further details). Infant transported to NICU via heated isolette with BBo2 given. Presently, Infant pink in room air. O2 sats93%. RR 30's. Infant noted to have GFR with diminished breath sounds. ABG obtained. Bp stable at present. Infant pink. No murmur. Heart rate 140's. BW 1370g. Infant NPO D10W infusing @80cc/kg/d. Abd. soft. Infant has not voided or stool. D/S 61. CBC & blood culture obtained. Mg level sent. Baby care given. Infant hypotonic. Mom viewed infant in dr. took photographs.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-27 00:00:00.000", "description": "Report", "row_id": 1788493, "text": "Neonatology Attending\n\nI updated parents in mother's room in L&D and discussed current status, plans and discharge criteria. Answered questions.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-27 00:00:00.000", "description": "Report", "row_id": 1788494, "text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: Infant in RA with sats 93-97. All grunting and flaring resolved. Only mild IC/SC retractions remain. Breath sounds initially diminished bilat are now clear and =. RR 30's-50's. No apnea or bradycardia noted. Occasional desats to 80's after crying or proceedures. Quickly resolved w/o intervention.\nA: Doing well in RA with occasional mild desats\nP: Continue close observation and monitoring. Document any spells.\n\n#2 Alt. in Nutrition\nO: TF=80cc/kg. PIV D10W at 60cc/kg and feeds started at 20cc/kg=5cc PE20 Q 4 hrs. Abd. is flat, soft with + BS, no loops. Girth 21.5-22. No aspirates or spits. Voiding 4cc/kg/hr since birth. No stools. Attempted D/S X 5, (using different machines) but machine unable to read D/S due to infant's HCT of 62.5. NNP notified. Plan to check Blood glucose by veinipuncture prior to next feeding at 2100.\nA: Infant beginning feeds\nP: Close observation and monitoring of feeding tolerance. Check Blood glucose with next feeding. Monitor I+0. Check 24 hr lytes and bili. Follow daily wts.\n\n#3 Possible Sepsis\nO: CBC and BC sent on admission. CBC w/o indication of infection. Improved resp. status. Temp and VS stable and WNL. Activity and tone improved. No sepsis risk factors. Not on antibiotics.\nA: No s/s of sepsis\nP: Continue observation for any s/s sepsis, but no treatment at present.\n\n#4 Alt. in Development\nO: Maintaining temp on open warmer, nested in sheepskin, positioned on side or prone. Sleeps well between cares. More active and improved tone this PM. No apnea or bradycardia.\nA: Appropriate for GA, improved activity as MgS04 wears off\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: in several times. Updated. Asking appropriate questions. Brought in sibling and grandmother. still in L+D. Unable to visit NICU yet. Pictures taken and sent up to mom.\nA: Involved, loving family\nP: Keep informed and support.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-28 00:00:00.000", "description": "Report", "row_id": 1788495, "text": "NPN 1900-0700\n\n\n#1 RESP\nPT CONTINUES IN R/A WITH SATS 92-96%. LSC AND EQUAL. IC/SC\nRETRACTIONS NOTED. RR 40-60'S. OCCATIONAL DRIFT TO MID 80'S\nTHAT QSR. NO SPELLS THUS FAR THIS SHIFT.\n#2 FEN\nTF 80CC/KG. IVF OF D10 VIA PIV @ 60CC/KG AND ENTERAL\nFEEDINGS OF PE20 @ 20CC/KG GAVAGED Q4HOURS. WT. 1.310KG\n(-60GMS). ABD BENIGN, SOFT AND FLAT. HYPOACTIVE BS. VOIDING\n3.3CC/KG IN PAST 18HOURS. AG STABLE 20CM. NO STOOLS SINCE\nBIRTH. 24HOUR LYTES AND GLUCOSE TO BE DRAWN THIS AM.\n#3 SEPSIS\nCBCD BENIGN, NO ABX STARTED. BC PENDING.\n#4 G&D\nPT IN SERVO ISOLETTE WITH STABLE TEMPS. PT REQUIRING FAIR\nAMT OF HEAT AT TIMES TO REMAIN WITH STABLE TEMP. ALERT AND\nACTIVE WITH CARES. MAEW. FONTANELLES SOFT AND FLAT.\n#5 PARENTING\n UP TO SEE INFANT IN EVENING. ASKING APPROPRIATE\nQUESTIONS. LOVING TOWARDS INFANT. INVOLVED INTACT FAMILY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-14 00:00:00.000", "description": "Report", "row_id": 1788570, "text": "Neonatology Attending\n\nDay 17\n\nRemains on nasal cannula at 75-100 cc/min. Mild retractions. RR 70-90s. No murmur. HR 150-160s. BP mean 56. Cardiac work up done yesterday. Passed hyperoxia test. CXR normal on . Hct 47.6 Plts 338k. Bilirubin 2.6/0.4. Weight 1605 gms (+70). TF at 150 cc/kg/d. BM 28 with Promod. Minimal aspirates. Passing guiaic negative stool. Stable temperature in open crib.\n\nRespiratory insufficiency. Monitoring closely. Gaining weight well. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-14 00:00:00.000", "description": "Report", "row_id": 1788571, "text": "Fellow note; physical exam\nAlert and actove. In NCO2 with mild subcostal retractions. Skin ruddy. AFOF. MMM. Lungs clear with good aeration bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd full, but soft, +BS. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-14 00:00:00.000", "description": "Report", "row_id": 1788572, "text": "Nursing Progress Note:\n#2 - F&N: TF at 150cc/kilo/day = 40cc's Q 4 horus of BM28\nwith PM. Tolerating feeds well over 40 min. Offered bottle\nthis am - uninterested. Abodmin soft and round. +BS.\nMinimal aspirates. No spits. Girth 24cm. Voiding and\nstooling with each diaper change. Receiving iron and vit e.\nFissures much improved - with criticaid creame.\n\n#4 - G&D: Temps stable in open crib. Alert and active with\ncares. Turned and repositoned with cares. MAE. AFSF. Hx of a\nnormal head US.\n\n#5 - : Mom and in this evening. Updated at the\nbedside. Independent with cares. Starting to do a little d/c\nteaching. Mom looking forward to putting the baby to breast\n- maybe this weekend.\n\n#8 - RESP: Remains in Low flow NC 100% - 50-100cc's. Remains\non caffeine. No spells. RR (50-80).\n\nCardiac work up done secondary to NC use - No murmur. 4 ext\nBps unremarkable. Passed hyperoxia test. CXR - neg. HCt\n47.6. Skin ruddy. Bili (2.6/0.4). Official EKG to be done\n.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 1788573, "text": "NPN 1900-0700\n\n\n1. FEN: WT=1655gms (up 50gms). TF=150cc/k/day BM28 with\nPM. Gavaged 41cc over 40\". well. Max asp = 5.2cc. 1\nvery small spit. V&S with each diaper change. Criticaid\napplied x2 secondary to skin breakdown. AG=23.5-24cm. Abd\nis round and appears slightly full, but is soft. Active bs.\n\n2. G&D: Infant wakes for some feeds. Alert and active\nwith cares. Sleeps well between cares. Brings hands to\nface. Uses pacifier to comfort self during gavage. Temps\nstable swaddled in open crib. AFSF. AGA.\n\n3. Parenting: No contact this shift.\n\n4. Resp: Infant remains in NC 100% and 50-75cc flow.\n(Mostly 50cc o/n). RR=60-70's. Occasionally low 80's.\nMild SCR. Breathing comfortably. Continues to have nasal\ncongestion. LS clear. O2 sats = 90-97%. No spells.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 1788574, "text": "Neonatology Attending Note\nDay 18\n\nCGA 34 1\n\nNC 100%, 50-125 cc. RR50-70s. No A&Bs. On caffeine. No murmur. HR 150-170s. BP 59/31, 41.\n\nWt 1655, up 50 gms. TF 150 cc/k/day BM28 w promod. All pg. Abd soft and full. Nl voiding. No stool.\n\nCriticaid to buttock excoriation.\n\nVit E and Fe.\n\nin open crib.\n\nA/P:\nO2 need still being investigated. Cardiology evaluation negative to date. CXR clear with no consolidation/or other changes. Will check gas. Will also send screening CBC and bld cx to r/o indolent infection.\n\nImmature feeding skills, will encourage po intakes.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-16 00:00:00.000", "description": "Report", "row_id": 1788709, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm30\nwith promd, 57cc q4 po/pg. Infant bottled 57cc so far\ntonight. Abdomen is benign, voiding. Continues with having\ntrace stools, glycerin supp. given. No spits, minimal\naspirates. On Diuril and K supps. A: Stable P: Continue to\nmonitor.\n\n#3 DEV S/O: Infant in , maintaining temps. Active with\ncares. Stirs before feeds. Sucks on pacifier. A: AGA P:\nContinue to support dev.\n\n#5 Parenting S/O: Mom and called tonight for updates.\nAsking about s wt gain. Mom states she will be in\ntoday. A: Involved, loving. P: Continue to support and\nupdate.\n\n#8 RESP/CV: Infant in NC 500cc, 60-70% FiO2. Infants lungs\nare clear with increasing upper airway congestion. RR\n50-70's. HR 150's, int murmer not heard tonight. BP stable,\ninfant appears /pale. No spells. A: Stable in NC P:\nContinue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-28 00:00:00.000", "description": "Report", "row_id": 1788765, "text": "NPN Days\n\n\n#2 FEN- TF= 130cc/kg/d of BM28 with PM. abd benign. voiding,\nno stool so far this shift. no spits. Pt po 40 and 45cc +BF\nx2. P- Will cont to monitor FEN.\n#4 G&D- Temp stable in open crib. and active with\ncares. waking for feeds. P- Will cont to monitor G&D.\n#5 Parenting- visiting this shift. Lac consult.\n asking approp ques. loving and caring. updates\ngiven. P- Will cont to encourage parental visits and calls.\n#8 Pt received and cont in NCO2 200% 21-30%. LS C+=.\nno spells so far this shift. UAC. P- Will cont to monitor\nresp status.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-29 00:00:00.000", "description": "Report", "row_id": 1788766, "text": "NPN\n\n\n#2 had 1 poor feed at 21:00 taking only 35cc but did\ngreat at 01:00 and 05:00 taking 65 and 70cc. Abd full, + bs,\nvoiding, no stool, rectal stim given. Weight up 15grams. A:\nfeeding well tonight P: no change at present\n#4 Stable in open crib. Sleeping between feeds, calm with\ncares. sucks some on pacifier. A: AGA P: cont to support\ndevelopment\n#5 Mom called, asking about weight and how feeding. Worried\nthat tube may need to go back in. A: involved family P:\ncont to support and infor.\n#6 cont in RA cannula of 200cc. with SaO2 >93 this\nshift. RR40-60, Color good, cont with mild SCR. A: stable in\nRA cannula P: no change at present.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-29 00:00:00.000", "description": "Report", "row_id": 1788767, "text": "Neonatology Attending\n\nDay 63- 40 5/7 weeks\n\nRemains in RA since 0800 this morning. RR 40-50s. Clear breath sounds. Minimal retractions. No murmur. HR 140-150s. No bradycardia. Weight 3055 gms (+15). TF at 130 cc/kg/d- BM 28 with Promod. Took 89 cc/kg and breast fed twice. Stable temperature in open crib.\n\nDoing well overall. Weaned to RA. Will continue to monitor cardio-respiratory status closely. Gaining weight. Improved feeding. Hopefully will be able to go home very soon.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 1788636, "text": "Nursing progress notes.\n\n\n#2 O: Total fluids max 130cc/kg/day. Baby not interested in\nbreastfeeding and when bottle was offered had a desat and\nbrady and required BBO2 and stim. No further PO feeds\noffered today. Gavage feeds given every 4 hours over 40\n. No spits, 1cc aspirates, (noted to be mint green at\n1300 feeding-Dr aware.),Abdomen benign, voiding and\n guaic negative stools. A: Tolerating feeds by\ngavage, No energy for PO feeding today. P: Continue NG\nfeeds and offer PO when baby is and eager to feed.\n#4 O: Temp stable in open crib. Baby is quiet today, not\nwaking much. No interest shown in feeding. A: Baby seems\ntired. P: Continue to support development.\n#5 O: Mother in this morning to hold and feed baby and was\ndisappointed at baby's increasing oxygen need. A: Involved\nfamily. P: Continue to keep informe.d\n#9 O: Murmur present, BP stable, pulses WNL. A: Murmur\nworked up by cardiology--benign. P: Continue to monitor.\n#8 O: Baby started the day in 150cc of 100% nasal cannula\noxygen and has increased to 300cc of 70 to 100% oxygen with\nincreased to 500cc and more at time when stressed (as during\nchest x-ray). Baby seems to have little reserve. Breath\nsounds clear and equal, mild retractions. Baby frequently\n to mid 80's and does not self resolve, requiring\nincreased oxygen. She also has had many to 70's\ntoday, mostly before changing to 300cc flow. Dr \naware and examined baby. A: Increasing oxygen need today.\nP: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-08 00:00:00.000", "description": "Report", "row_id": 1788676, "text": "PCA Progress Note, 7a-7p\n\n\nFEN:\n TF:130cc/kg/D of BM30w/PM. Alt Po/PG. PGing full volumes\nover 1 hour. At afternoon care infant bottled a small amt of\nvolume while the remainder was gavged. Attempted to BF at\nlater care and latched on, although suck reflex was absent.\nFull feeding was given after BFing attempt. Tolerating all\nfeeds well w/ minimal aspirates and small spitx1. Voiding\nand w/ each diaper chg. Abd is benign w/ active BS.\nRemains on KCL, Fe, and Vit E. Please refer to Pt's chart\nfor additional FEN data. Continue to enocurage and support\nPO feeds.\n\nDEV:\n Pt's temp remains stable while swaddled in . Infant is\nbegining to wake for feeds, is and active w/ most\ncares, and continues to sleep well in between each care.\nInfant sucks on fingers for comfort and settles well w/\npacifier. Continue to encourage and support developmental\nmilestones.\n\nPAR:\n Mom was in for last care this shift w/ sibling. Mom\nattempted to BF and held infant after. Mom is w/\ncares, and affectionate toward the infant. Continue to\nupdate and support.\n\nRESP:\n Infant remains on NC at 400cc flow of 75-80 cc flow. O2\nsats have been >90% so far this shift. LS:cl/=. SC retrax\nnoted. Please refer to Pt's chart for additional RESP data.\nContinue to O2 as tolerated.Continue to monitor and\nsupport RESP status.\n\nCV:\n Soft int M heard. Infant appears pale , and well\nperfused. Cap refil is good. Please refer to Pt's chart for\nadditional CV data. Continue to monitor and support CV\nstatus.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-08 00:00:00.000", "description": "Report", "row_id": 1788677, "text": "Agree with co-workers note above\n" }, { "category": "Nursing/other", "chartdate": "2195-10-04 00:00:00.000", "description": "Report", "row_id": 1788523, "text": "NPN NOCS\n\n\n2. O: Wt 1315, up 25gms. TF remain at 150cc/kg of BM22.\nGavaged over 40min. Abd benign. Min residual. Stool(guiac-)\nand voiding. No spits. A: feeds. P: Continue with plan.\n\n4. O: Alert and active with cares. Temp stable in servo\nisolette. A: AGA. P: Continue to support dev needs.\n\n5. No contact from thus far this shift.\n\n6. O: Ruddy. Remains under single phototherapy. A:\nHyperbili. P: Continue with plan.\n\n7. O: Antibiotics as ordered. VSS. BC remains neg to date.\nA/P: Continue to monitor. F/U with final blood culture\nresult.\n\nResp: Remains in RA. LS clear. O2 sats 92-97%. On caffeine,\nno spells.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-04 00:00:00.000", "description": "Report", "row_id": 1788524, "text": "Neonatology\nRA. Comfortable\n\nWT 1315 up 25. ON full volumes and now receiving 22 cal. WIll advance to 24 cal. ABdomen benign. WIll advance feeds to 24 cal.\n\nCOntinues on abx. Given stable clinical state, negative repeat BC and difficulty with IV access, will plan to dc abx and follow cx results and clincial course.\n\nBili in 4 range. On single photorx. Repeat bili pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-04 00:00:00.000", "description": "Report", "row_id": 1788525, "text": "NURSING PROGRESS NOTE\n\n\n#2 O: TF 150cc/k/d BM24 (inc cals from 22), all feeds on\npump over 45mins and well w/o spits or asp. abd softly\nround, no loops, active bowel sounds. vdg qdiaper w/sm\nstools all guiac neg. Hep lock restarted in R arm after\nmultiple attempts-poor IV access. A: feeds well P: cont\nto inc cals as to optimize nutrition. Will start vits\nthis evening.\n#4 O: temp stable on servo in heated isolette. pacifier\nintermittently to settle. prefers to be prone, stretches out\nof boundries. A: AGA P: cont to assess and support\ndevelopmentally, HUS on Monday.\n#5 O: mom, MGM, sib in to visit just after bloodwork and IV\nrestart. updated on present status, planned not to hold as\nhad just been very stressed. Mom asking appropriate\nquestions re: progress, meds, feeds, etc. A: loving family\nP: cont to support.\n#6 O: single bili lite w/eyes protected. repeat bili 4.2/.2\nP: cont tx.\n#7 O: repeat blood cx neg to date, Vanco and gent dc'd L eye\nw/goopy green drainage, warm H2O soaks to clean. A: r/o\nsepsis completed for blood cx, may need eye cx. P: monitor\neye drainage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-13 00:00:00.000", "description": "Report", "row_id": 1788567, "text": "NICU nursing note\n\n\n2. FEN=O/TF cont at 150cc/k/d of BM28PM gavaged over 50min.\nAbd benign. (Please refer to flowsheet for assessment.) Sm\nspit x2. Voiding/stooling, heme(-). Criticaid applied with\nQcare. Bum sl . Cont on Vit E and iron. A/Tolerating\ncurrent regime. P/cont to monitor for feeding intolerance.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert, active,\nand irritable with cares. Slept in short naps between\nfeeds. A/Alt in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom and in to visit. Both updated by this\nnurse. Mom participating in all care. A/appropriate and\nactively involved. P/Cont to support and educate .\n\n8. Resp=O/Cont in NCO2 FIO2 100% 50-125cc/min flow. No\nspells. Cont on caffeine. Sats consistently in mid-low\n90's. A/Stable on NCO2. P/Cont to monitor for resp\ndistress. Cont to attempt to wean O2.\n\n9. CV=O/Cardiac eval ordered r/t inability to wean O2. 4\next bps done. Fellow aware of results. Hyperoxia done.\nPassed per RT. 10lead EKG attemped without success. A/CV\nstatus stable. No murmur. VSS. P/Reattempt EKG to\ncomplete cardiac eval.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-25 00:00:00.000", "description": "Report", "row_id": 1788615, "text": "Nursing progress Note\n\n\n#2 O: TF 150cc/k/d BM28 w/PM, all pg feeds this shift(mom\nhere this afternoon but gave baby bath vs BF) and well\nw/o spits or asp. Abd softly round, active bowel sounds, vdg\nand . Criticaid to butt for irritation. Vits as\nordered. A: slow to po P: offer bottle 1x shift.\n#4 O: temp stable in open crib, waking early for some feeds.\nalert w/cares. bath done w/mom and well. A: AGA P: cont\nto assess and support developmentally.\n#5 O: mom here to visit, observed bath. held for pg feed.\nasking appropriate questions, very pleased w/how well baby\nis doing. A: loving family P: cont to support and update.\n#8 O: remains in low flow nasal cannula O2 100% 100-125cc.\nLungs clear/equal, upper airway congestion, nares sx x1 for\nlg plugs. baseline sc retractions, RR 40's-60's. no apnea or\nbradycardia episodes noted, but frequent drifts when trying\nto wean O2. A: still needing O2 P: per prsent care, wean as\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-26 00:00:00.000", "description": "Report", "row_id": 1788616, "text": "Nsg Note 1900-2300.\n#2FEN\nBaby cont to receive BM28 with promod at 150cc/kg. Wt up\n50g. At 2100, baby awake and . She bottled 30cc and\nthen tired. remainder gavaged. abd soft, active bowel\nsounds. asp. no spits. Somewhat gassy though.\nA. feed.\nP. cont to monitor.\n#4Dev\n with cares. temp stable in an open crib. Learning to\nbottlr.\nP. imonth HUS planned for today.\n#5Parent\nNo contact.\n#8Resp\nLungs clear but nasal stuffiness noted. Suctioned with tb\nsyringe for small amt. Baby remains in nasal cannula. She\ndid drift to 82 and required increase in O2 flow. No spells,\nShe remains in nasal cannul with 75 150cc flow. She did\nrequire increase in O2 to 200cc to bottle. Increase work of\nbreath noted with feed. Mild IC/SC retractions noted.\nA. Cont to have an O2 requirement.\nP. cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-26 00:00:00.000", "description": "Report", "row_id": 1788617, "text": "Baby remains in NC 02 100% 100-200cc flow tonight. LS CTA occassional quick drifts mostly self resolving. Weight up 50 gms on BM 28kcal/oz. ? decrease calories today.No contact from tonight.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-26 00:00:00.000", "description": "Report", "row_id": 1788618, "text": "Neonatology\nDOing well. REmains in NCo2. COmfortabely tachypneic. Increased WOB and O2 with feeds. No spells.\n\nWt up 50. Tolerating feeds at 150 cc/k/d of 28 cal. Abdomen bneign. STill req gavage. Will attempt fluid restriction to 130 and monitor effect on resp illness.\n\n\nTemp stable in open crib.\n\nUrine CMV sent this weekend.\n\nCOntinue to await maturation ofresp control and feeds.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-26 00:00:00.000", "description": "Report", "row_id": 1788619, "text": "Fellow note; physical exam\n and active. Breathing comfortably in NCO2. Skin . AFOF. MMM. Lungs clear with good aeration. RRR. Nl S1, S2. soft systolic murmur at LSB radiating to the back c/w PPS. Normal femoral pulses. Abd soft, ND, +BS. Extremities warm and well-perfused. No edema. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-29 00:00:00.000", "description": "Report", "row_id": 1788768, "text": " Physical Exam\nSee Dr. note for plan of care as discussed on rounds.\n\nInfant is and active in open crib. Sucking on pacifier. Color .\nAFSF, sutures approximated.\nLungs are clear and equal with moderate subcostal retractions. Well aerated. Symmetrical movement.\nNo murmur, RRR, brisk capillary refill. +2/equal peripheral pulses.\nAbdomen is soft, round, +BS, no loops, no HSM.\nNormal female genitalia, patent anus.\nExtremeties are , warm, spontaneous movement in all, symmetrical tone. +Moro, +grasp, +suck, +gag.\n , SNNP\n" }, { "category": "Nursing/other", "chartdate": "2195-11-29 00:00:00.000", "description": "Report", "row_id": 1788769, "text": " Physical Exam\nExamined infant and agree with above\n" }, { "category": "Nursing/other", "chartdate": "2195-11-09 00:00:00.000", "description": "Report", "row_id": 1788678, "text": "NPN 7p7a\n\n\nFEN\nWt 2.495 (+20) TF 130cc/k/d restricted. PO/PG alternating.\nTook full bottle x 1 but less interested at alternate\nfeeding. Abd soft, active BS. Voiding and . Gaining\nweight. Lights sent and pending. DS 84. Learning to PO.\nMonitor weight and exam.\nG/D\nInfant in with stable cool temps, 97.9-98. Hat placed\non. A/A with cares. Wakes for some feeds. MAEs. FS&F. AGA.\nSupport G/D.\nResp\nInfant on NC 400 cc flow needing 70-80% fio2. Some long slow\ndrifts to the 70-80s but recovers on own with out increase\nin 02. Increased WOB during bottling, becomes tachapenic,\nsome nasal flaring. LSC. Upper airway congestion, suc x 1\nfor thick plug. Infant needing flow and o2 support. Monitor\nand support resp status.\nC/V\nInfant with audable murmur. pulses faint but\npalpable. Widened pulse pressure. . NAD. Monitor and\nsupport CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-09 00:00:00.000", "description": "Report", "row_id": 1788679, "text": "Neonatology\nRemains in NCO2 flow at 400 cc and 75-80%. Slightly increasedresp rate at times. WOB sl increased, but at baseline. Able to feed well.\nMurmur noted as before. Followed by cardiology. echo shows small PDA said to be hemodynamically insignificant.\nLAsix given yesterday without marked effect.\n\nWt 2495 up 20. TF at 130 cc/k/d of 30 cal. Took full bottle once overnight. Dstix 84.\n\nLytes notable for improved CL and decreased HCO# now on KCl supps.\n\nWill continue to follow resp status. Consider diuretics in coming weeks.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-19 00:00:00.000", "description": "Report", "row_id": 1788721, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=130cc/kg/day of BM30w/PM. Alt PO/PG. \nfeeds well. No spits thus far. asp thus far. Belly\nsoft, no loops. Infant voiding, no stool thus far. Cont\nw/nystatin. P cont to offer PO feeds as .\n4. DEV O/A remains in an with stable temp.\nA/A w/cares. Sucks pacifier, thumb. P cont to assess dev\nneeds.\n5. O/A Mom called for updates. P cont to\nsupport, educate.\n8. Resp O/A Rec'd inf in NC. Inf remains in NC 500cc\n45-55%. Occ'l drifts self resolved. P cont to assess resp\nneeds.\n9. CV O/A Inf well perfused. Murmur heard this\nshift. P cont to assess cv needs.\n10 Thrush O/A Inf cont on nystatin P cont to monitor.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-19 00:00:00.000", "description": "Report", "row_id": 1788722, "text": "Neonatology\nStill requiring NCo2 at 500, 45-55%. RR down to 30s and 60s. Less variability in sats over recent days. WOB contyinues to be decreased over previous baseline.\n\nWt 2785 up 70. Tolerating feeds at 130 cc/k/d of 30 cal. Abdomen benign. Bottling once per shift.\n\nNystation orally and to[pically for thrush.\n\nCOntinue to awiatability to wena. WIll observe course through beginning of week on diuril and if not significant weaning will consider other eval incl perhaps BA Swallow for ? aspiration\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-19 00:00:00.000", "description": "Report", "row_id": 1788723, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, soft murmur auscultated. She is comfortable in NCO2 500ccs/45-55%. Breath sounds clear and equal. No spells over last 24 hours. She is tolerating full volume po/pg feeds. Abd soft, active bowel sounds, no loops. Voiding and . Stable temp in open crib. Remains on Nystatin suspension for oral thrush. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-14 00:00:00.000", "description": "Report", "row_id": 1788568, "text": "NNP 7p-7a\n\n\nFEN:\n Tf: 150cc/kg/D of BM28w/PM. Full volume is being gavaged\nover 50 mins for hx of spits. Infant is tolerating feeds\nwell, w/ no spits anf minimal aspirates. Abd is benign w/\nactive BS. Infant is voiding and stooling w/ each diaper\nchg, heme neg. Applying criticade at each diaper chg to\ndiaper area for fissures and breakdown. Area appears less\nreddened and irritated. No visible bleeding. Please refer to\nPt's chart for additional FEN data. Continue to monitor and\nsupport current FEN data.\n\nDEV:\n Infant's temp remains stable while swaddled in OAC. Infant\nis alert and active w/ cares, though irritable. Infant is\nsleeping well in between cares. SHe settles well w/\npacifier. Continue to encourage and support developmental\nmilestones.\n\nPAR:\n No contact from so far this shift.\n\nRESP:\n Infant remains on NC in 100% o2 w/ 75-140cc flow. O2 sats\nare stable Ic/Sc retrax are noted. LS: cl/=. Mild upper\nairway congestion is present. RN suctioned infant during 1st\ncare of shift. No desats or spells so far this shift.Please\nrefer to Pt's chart for additional RESp data. Continue to\n o2 requirment snd support current plan.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-24 00:00:00.000", "description": "Report", "row_id": 1788611, "text": "Neonatology- Physical Exam\n\nInfant remains in NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Soft murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-24 00:00:00.000", "description": "Report", "row_id": 1788612, "text": "NPN 0700-1900\n\n\n#2 : Infant remains on TF 150cc/k of BM28 with Promod\nvia NGT feedings. Infant BF fair, interested and took\nseveral sucks. Mom's nipple is too large for infant's mouth.\nAbd. soft and nondistended, good bowel sounds, voiding and\n. . gavage feeds well. A: Alt in FEN P Cont to\nassess for feeding intolerencence, wt q day.\n#5 PARENTING O: Mom and in to visit, mom independent\nwith cares, updated on infant's progress. A: Involved and\nconcerned family P: cont to inform and support family as\nneeded.\n#8 RESP O: Infant remains on NC 100% 02, 50-200cc flow. RR\neasy 50-60's with mild retractions, BBS equal and clear,\nwell aerated. Decreased 02 requirment today, tolerating\ndifferent positioning well. No spells today. A: ALt in RESP\nP: cont to assess for increased resp distress, monitor and\ndocument for spells.\nUrine for CMV sent to lab.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-25 00:00:00.000", "description": "Report", "row_id": 1788613, "text": "NPN 2100-0700\n\n\n2. O: Wt.+45g 1975g TF=150cc/kg/d. Infant receiving BM28\nwith promod 49cc every 4 hours via gavage. Minimal aspirates\nnoted. No spits noted. Bottled 30cc x 1. Abdomen soft. +b.s.\nVdg q.s. Trace stool noted x 1. A: learning to bottle P:\nContinue to encourage po feeds.\n\n4. O: maintaining temperature in open crib. Swaddled.\nBRings hands to face. MAE. Alert with cares. Sucks on\npacifier at times. Reddened buttocks noted. Criticaid\napplied. No bleeding noted. A: AGA P:Continue to support\ndevelopment.\n\n5. O: No parental contact noted thus far. P: Continue to\nupdate,educate and support.\n\n8. O: Remains in her nasal cannula 50-125cc in 100%Fio2. RR\n50-60's with mild retractions noted. LS clear bilaterally.\nOcc. Upper airway congestion noted. No A&b's noted thus\nfar. O2 sat drifts occur. A: o2 requirement persists. P:\nContinue to monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-04 00:00:00.000", "description": "Report", "row_id": 1788658, "text": "Neonatology Attending\nDOL 38 / CGA 37 weeks\n\nRemains on NC 500 cc/ of 50-75% FiO2 with no current distress. Most recent lasix Sunday. ABG 7.42/58.\n\nMurmur persists. BP 68/30 (44).\n\nWt 2290 (+50) on TFI 130 cc/kg/day BM30PM, tolerating well. Bottling once per shift for partial volumes. Abdomen benign. Voiding and normally.\n\nTemperature stable in open crib. HB adminstered, hearing apssed.\n\nA&P\n31-4/7 week GA infant with metabolic alkolosis\n-Continue on NC supplementation\n-Electrolytes will be rechecked tomorrow along with nutrition tomorrow\n-Weight gain is acceptable at 12 g/kg/day. Continue to follow growth\n- up to date\n" }, { "category": "Nursing/other", "chartdate": "2195-11-04 00:00:00.000", "description": "Report", "row_id": 1788659, "text": "Neonatology Attending\nAddendum - Physical Examination\n\nwell-appearing infant\nHEENT AFSF\nCHEST no retractions; good bs bialt; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM LSB without radiation\nABD soft, non-distended; no organomegaly; no masses; bs active\nCNS active, , resp to stim; axial and appendicular tone normal; suck/root/gag normal; grasp symm\nINTEG normal\nMSK normal\n" }, { "category": "Nursing/other", "chartdate": "2195-11-04 00:00:00.000", "description": "Report", "row_id": 1788660, "text": "Clinical Nutrition\nO:\n~37 wk CGA BG on DOL 38.\nWT: 2290 g (+50)(~10th to 25th %ile); birth wt: 1370 g. Average wt gain over past wk ~12 g/kg/d.\nHC: 31.75 cm (~25th to 50th %ile); last: 30.5 cm\nLN: 44 cm (~10th to 25th %ile); last: 42.5 cm\nMeds include Fe and Vit E and KCl.\n due this wk.\nNutrition: 130 cc/kg/d BM 30 w/ promod, po/pg. Infant po's ~1 x per shift; takes ~ of volume po. Average of past 3 d intake ~132 cc/kg/d, providing ~132 kcal/kg/d and ~3.6 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. due. Electrolyte results noted; infant w/ met. alkalosis. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is not meeting recs for wt gain of ~15 to 20 g/kg/d. Unable to increase fluids due to lung status. Discussed w/ team increasing kcals to 32/oz, but since we would need to increase polycose which would add to load, it was decided to continue w/ current feeds and monitor growth due to risk of worsening CO2 retention w/ additional . HC and LN gains are both exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-14 00:00:00.000", "description": "Report", "row_id": 1788705, "text": "Student Neonatal Nurse Practitioner Note-PE\nSee Dr. note for discussion on rounds and plan of care.\n\nInfant is lying supine in open air crib, swaddled. AFSF. Color .\nLungs: Clear and equal with good aeration. Mild subcostal retractions. Nasal cannula in place.\nCV: Soft grade murmur. RRR. , well perfused with brisk capillary refill. +2 femoral pulses.\nAbd: Soft, round, , no loops, no masses, no tenderness. No HSM. +BS.\nGU: Normal female genitalia, patent anus.\nEXT: Warm and well perfused. Symmetrical tone. MAE. Spine , no dimple.\nNeuro: +Moro, +suck, +grasp, +gag.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-19 00:00:00.000", "description": "Report", "row_id": 1788724, "text": "NPN 0700-1900\n\n10 Thrush\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get BM 30\nwith promod, 60cc q4h po/pg. Infant bottled 60cc x2 and\nbreastfed >20min. Abdomen is benign, voiding and .\nNo spits or aspirates. On diuril and KCL supps. A:\nTolerating P: Encourage po feeding.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive with cares. Waking before feeds. Sucking on pacifier.\nMom gave today. Infant tolerated well. A: AGA P:\nContinue to support.\n\n#5 Parenting S/O: Mom in for 5pm care. Gave infant a ,\nvery with cares. Breastfed. Asked appropriate\nquestions. A: Involved, loving. P: Continue to support and\nupdate.\n\n#8 RESP/CV S/O: Infant remains in NC 500cc, 45-60% FiO2\ntoday. Lungs sounds are clear, sc/ic retractions. RR\n30-60's. HR 130-150's. No spells, occasional drifting. A:\nStable in RA, seems more comfortable. P: Continue to\nmonitor.\n\n\nREVISIONS TO PATHWAY:\n\n 10 Thrush; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-19 00:00:00.000", "description": "Report", "row_id": 1788725, "text": "Rehab/OT\n\nMet with mom. Discussed back to sleep, tummy time, and developmental play positions. Recommend EI follow up to monitor developmental milestones.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-03 00:00:00.000", "description": "Report", "row_id": 1788786, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\naFOF. breath sounds clear and equal> nl S1S2, noaudible murmru. and well perfused. abd benign, no HSM. Acitve bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-03 00:00:00.000", "description": "Report", "row_id": 1788787, "text": "NPN 0700-1900\n\n\n#2 O: TF= 130cc/kg/d. Infant taking 70cc's of BM26 via all\nbottle feeds q 4h. Cals to be reduced to 24. Abdomen benign;\nvoiding, no stool. No spits. A: Tolerating feeds. P: Cont to\nmonitor.\n\n#4 O: Maintaining temp in . Awake and with cares;\nsleeping well between. Waking on own for feeds. A: AGA. P:\nCont to support development.\n\n#5 O: Mom called x1 for update. Asking appropriate\nquestions. Mom does not plan to be in today. A: Involved. P:\nCont to support and update.\n\n#8 O: Remains in RA. O2 sats maintained 92-99%. RR 30's-60's\nwith mild SC retractions. No spells this shift. On diuril\nand kcl as ordered. A: Stable in RA. P: Cont to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-04 00:00:00.000", "description": "Report", "row_id": 1788788, "text": "NPN 1900-0700\n\n\nFEN: wt=3165g (up 25g). TFmin 130cc/kg/d of BM24. Yest TFI\n117cc/kg. Bottling 40-80cc q1.5-4hrs. Abdomen soft, +BS, no\nloops, sm spit X1, voiding, no stool.\n\nDEV: Temps stable, swaddled in open crib. Wakes for feeds.\n and active with cares. Sleeps well between. Hands to\nface. Takes paci.\n\n: No contact thus far.\n\nResp: In RA. RR 20-50's. O2sat 94-98%. LS clear and equal.\nOn diuril and KCl supps. No or spells.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-04 00:00:00.000", "description": "Report", "row_id": 1788789, "text": "Neonatology\nDoing well. Remains in RA. NO spell.s Comfortable apeparing. Day of brady countdown. AHving some with feeds.\n\nWt 3165 up 25. TF at 130 cc/k/d. ABdomen benign.\nDown to 24 cal feeds.\n\nWill repeat car seat test.\n\nPotential for discharge over weekend.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-25 00:00:00.000", "description": "Report", "row_id": 1788614, "text": "NICU ATTENDING NOTE\nDay of life 28\nStable in 50-100 cc of\n100% nasal cannula.\nRR 50-60 mild upper airway\ncongestion\nHR 160's\nweight grams up 45 BM 28 with promod\nwill po once per shift taking\nhalf of a feed.\n\nvoiding and \n\nurine for CMV pending\n\nPlan: overall making progress\nstill needing oxygen\nhead ultrasound tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-03 00:00:00.000", "description": "Report", "row_id": 1788654, "text": "Neonatology- Physical Exam\n\nInfant remains in NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-03 00:00:00.000", "description": "Report", "row_id": 1788655, "text": "Neonatology Attending Note\nDay 37\n\nNC 500cc, 60-70%. RR50-60s. 1 desat yest, none on nights. +UA congestion. No A&Bs. +murmur. HR 160s. Mildly edematous. BP 68/30, 46.\n\nWt 2240, up 50 gms. TF 130 cc/k/day of BM/PE30 w promod. PO/PG. well. Nl voiding and . On K supps, Vit E and Fe.\n\nRenal u/s normal.\n\nABG 7.42/58/89/39/10\n137/5/93/40/18/0.3\n\nA/P:\n - Continues w/ meatbolic alkalosis and pulm aveolar dz. Remainder of multisystem evaluation negative (renal, ID, cardiac)\n - Con't to support resp need, KCL to aid in metabolic alkalosis, no change to nutritional plan.\n - Diuretic on hold till metabolic state improved.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-03 00:00:00.000", "description": "Report", "row_id": 1788656, "text": "Nursing note\n\n\n#2 FEN O: Remains on 150cc/k of bm30 with promod. Tolerating\ngavage feeds of 49cc over 45 minutes without spits or\naspirates. Bottle fed once and took 22cc over 20 minutes\nwith the yellow nipple. Tires at the end. Abdomen remains\nbenign. Good bowel ounds heard. No loops noted. Child\nvoiding and well. P: will continue to offer the\nbottle if child interested and will monitor weight gain.\n#4 DEV O: Child remains in open crib. TEmp stable. and\nactive with cares. Sleeps between cares. Learning to bottle\nfeed. P: will continue to support the child's coping skills.\n#5 Parenting O: mom one. Status report given.\nStoppped by briiefly to pick up bottles and drop off Bm but\ndidn't visit child due to illness. P: Will continue to\nsupport and inform .\n#8 RESP O: Child remains on nasal cannula at 500cc and 55-70\npercent. Breath sounds are clear and equal. Mild subcostal\nretractions noted. P: Will continue to monitor WOB and\ncontinue with the plan.\n#9 CV O: No murmur heard this shift. Pulses equal times\nfour. P: will monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-15 00:00:00.000", "description": "Report", "row_id": 1788706, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 57cc q4h po/pg. Infant bottled 55cc and 57cc\ntonight. Abdomen is benign, voiding and no stools. No spits,\nminimal aspirates. Lytes drawn, results pending. KCL supps.\nA: Tolerating feeds. P: Continue to encourage po feeds.\n\n#4 DEV S/O: Infant in , maintaining temps. Active with\ncares tonight, woke for feedings x2. Sucking vigorously on\npacifier. A: AGA P: Continue to support dev.\n\n#5 Parenting S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#8 RESP/CV S/O: Infant in 500cc NC, FiO2 55-70% tonight.\nLungs are clear with upper airway congestion. RR 50-70's, HR\n160's. No spells tonight. Appears , well perfused.\nGetting diuril, generalized edema. A: Stable P: Continue to\nsupport and monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-15 00:00:00.000", "description": "Report", "row_id": 1788707, "text": "Neonatology Attending\n\nDOL 49 CGA 38 5/7 weeks\n\nOn NCO2 500 cc 60-70% with sats 90-93%. R 50s-80s. Significant upper airway congestion with some retractions. Continues on diuril.\n\nNo murmur. BP 76/42 mean 52\n\nOn 130 cc/kg/d BM 30 with promod. Bottles 1-2x/shift. Occ aspirate. Voiding. small amounts. 136/5.5/97/33 Wt 2655 grams (up 20).\n\nMother visiting and up to date.\n\nA: Stable. CLD with O2 reqirement. Feeding and growing.\n\nP: Monitor\n Wean O2 as tolerated\n Continue fluid restriction and diuril\n Glycerin suppository\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-27 00:00:00.000", "description": "Report", "row_id": 1788760, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral; sleeping infant in open crib, nasal cannula O2\nSkin: warm and dry; color \nHEENT: anterior fontanel open, level; sutures open/opposed; symmetric facial features\nChest: baseline sternal and intercostal retractions; breath sounds well-aerated, essentially clear, referred upper nasal congestion\nCV: RRR; murmur not appreciated; femoral pulses +2\nAbd: sfot; no masses; + bowel sounds; cord off, umbilicus healing\nGU: normale female\nExt: moves all\nNeuro: easily roused to drowsy state; + suck; + grasps; symmetric tone\n" }, { "category": "Nursing/other", "chartdate": "2195-11-27 00:00:00.000", "description": "Report", "row_id": 1788761, "text": "NPN 0700-1900\n\n\n#2 O: TF= 130cc/kg/d. Infant taking 70-75cc's of BM 28 with\npromod q 4h via all bottle feeds. NG tube remains out.\nAbdomen benign; voiding , sm stool. No spits. Remains on vit\nE, iron, prune juice, kcl, diuril and now bactroban as\nordered. A: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Infant maintaining temp in . Awake and with\ncares; waking on own for feeds. AFSF. Swaddled in blanket;\nsucks on pacifier when offered. A: AGA. P: Cont to support\ndevelopment.\n\n#5 O: Mom called x1 for update. Plans to eb in tomorrow. A:\nInvolved. P: Cont to support and update.\n\n#8 O: Infant remains in NC o2 200cc's of flow at 21-25%. LS\nclear and =. RR 30's-50's with mild SC retractions. No\nspells. A: Stable in NCo2. P: Cont to monitor and wean as\ntolerated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-09 00:00:00.000", "description": "Report", "row_id": 1788546, "text": "npn 1900-0700\n\n\n#2 fen\ntf 150cc/kg of bm26 with promod gavaged q4hours. wt. 1.445kg\n(+25gms). abd benign. voiding and stooling with every diaper\nyellow stools. multiple fissures around rectum, desitin\napplied. ag stable 21cm. no aspirates or spits.\n#4 g&d\npt in off isolette with stable temps. alert and active with\ncares. maew. fontanelles soft and flat. no interest in\nsucking on binki.\n#5 parenting\nmom called in evening for update. updated and asking\nappropriate questions. involved and loving parent.\n#8 resp\npt continues on nc fio2 100% with flow 25-75cc. lsc and\nequal. rr 40-60's. occational drift in o2sat, usually\noccuring during feeding time. spell x1 that qsr.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-09 00:00:00.000", "description": "Report", "row_id": 1788547, "text": "Neonatology Attending\n\nDay 12\n\nRemains on low flow nasal cannula. Occasional desaturations with feeds. No murmur. Had one bradycardia. Weight 1445 gms (+25). On BM 26 with Promod. Tolerating feeds well. Stable temperature.\n\nMinimal oxygen requirement. Monitoring and weaning oxygen as allowed. Gaining weight well. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-09 00:00:00.000", "description": "Report", "row_id": 1788548, "text": "Nursing Progress Note:\n#2 - F&N: TF at 150cc/kilo/day = 36cc's of BM26 with PM.\nTolerating feeds well over 40 min. No spits. Minimal\naspirates. Girth 20.5 - 21cm. Voiding and stooling. Guiac\nneg. Fissures appreciated. Remains on vit e and iron.\n\n#4 - G&D: Temps stable in off isolette. Wrapped. Alert and\nactive with cares. MAE. AFSF. Hx of Normal Head US.'\n\n#5 - : Mom, Grandma and Brother here visiting this\nafternoon. Updated at the bedside. Indepent with cares.\nHeld.\n\n#8 - RESP: Remains on Low flow NC. FIO2 (25-75cc's). Lungs\nclear and equal. Mild retractions. One quick spell - self\nresolving. Remains on caffeine.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-09 00:00:00.000", "description": "Report", "row_id": 1788549, "text": "Fellow note; physical exam\nSleeping comfortably in mom's arms. Breathing comfortably in NCO2. AFOF. MMM. Lungs CTA bilaterally. Good aeration. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Good cap refill. Abd soft, nondistended, +BS. Moving all extremities. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-10 00:00:00.000", "description": "Report", "row_id": 1788550, "text": "npn 1900-0700\n\n\n#2 fen\ntf 150cc/kg of bm26 gavaged fq4hours. wt. 1.490kg (+70gms).\nabd benign. voiding and stooling qdiaper change. multiple\nfissures around rectum, desitin and a&d applied qdiaper\nchange. minimal aspirates, no spits. ag stable 21cm.\n#4 g&d\npt in off isolette with stable temps. alert and active with\ncares. maew. sucking on binki. fontanelle soft and flat.\n#5 parenting\nno contact.\n#8 resp\npt continues on nc fiow 100% with flow 35-75cc. lsc and\nequal. rr 50-80's. sc/ic retractions noted. tb sux for\nmoderate thick yellow from both nares. no spells. occational\ndrift to low 90's high 80's.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-10 00:00:00.000", "description": "Report", "row_id": 1788551, "text": "Newborn Med Attending\n\nDOL#13. Cont in low flow O2 per NC. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1490 up 70, 150 cc/kg/d BM26 with PM.\nA/P: Growing infant with AOP, on caffeine. Monitor for spells. Advance cals to BM28.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-04 00:00:00.000", "description": "Report", "row_id": 1788790, "text": "Clinical Nutrition\nO:\n~41 wk CGA on DOL 68.\nWT: 3165g(+25)(25th-50th %ile); birth wt: 1370g. Average of wt gain over past wk ~26g/kg/d.\nHC:34.5cm(50-75th %ile); last wk:34cm\nLN: 47.5cm(~25th %ile); last wk: 46.5cm\nMeds include: Diuril, KCl, Fe, prune juice\n not needed.\nNutrition: 130cc/kg/d as BM 24 w/ 4cal/oz of Enf powder; all po's. Feeds just decreased yesterday due to good wt gain & in preparation for discharge. Average of past 3d intake ~136cc/kg/d; projected intake for next 24hrs based on average intake ~109kcals/kg/d and ~1.8g pro/kg/d.\nGI: Abdomen benign; X1 small spit.\n\nA/Goals:\nTolerating feeds w/o GI problems except for spit as noted above; all po's (some uncoordination @ end of feeds & occasional w/ feeds noted). not needed. Will need PVS prior to discharge. Current feeds & supps meeting weaned recs for kcals/vits/mins. Protein not quite meeting weaned rec of ~2.2g pro/kg/d but is gaining well & growth chart looks good; still w/ some uncoordinated feeds at end of feeds, intake will increase if coordination improves, if not, may need to increase TF if possible. Otherwise, growth is meeting recs for WT/HC/LN gains. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-03 00:00:00.000", "description": "Report", "row_id": 1788521, "text": "Neonatology Attending Progress Note\nNow day of life 6 for this 31 week gestation infant.\nIn RA.\nRR 40-60s.\nOn caffeine - started because of initial apnea/bradycardia.\nNo apnea and bradycardia in several days.\n\nHR 130-150s.\nBP MAPS 40-50s\n\nWt. down 5gm to 1290gm on 150cc/kg/d of MM or PE - feedings well tolerated by gavage.\nNormal urine and stool output.\n\nID - positive blood culture - G pos cocci\nOn Vanco and gent.\nFU blood culture is negative so far.\n\nBili - on double phototherapy - yesterday 7.1/0.3\n\nHct - 64% on the 25th\n\nAssessment/plan:\nSteady progress continues.\nWill continue with antibiotics.\nWill consider discontinuing caffeine if continues to be apnea free.\nCaloric density up to 22kcal/oz today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-03 00:00:00.000", "description": "Report", "row_id": 1788522, "text": "#1 RESP\ns/o: BS clear and equal in RA. No spells. A/P: Resolve\n#2 FEN\ns/o: Abd full/soft. Adv to 22 cal BM/PE today. cont to \nwell with min asp and stable girth. +BS bilat. Stool G trace\n+ yet fissure noted. No spits. Lytes today 141/5.1/106/24\nDS- 118 and triglycerides- 319. A: Increase cals to promote\ngrowth. P: Cont to mtr tolerance closely. Report changes\n#4 DEV\ns/o: Nested in sheepskin on servo in heated isolette. Tone\ngood. Alert with cares. Sucking on pacifier. Held in\nkangaroo fashion with mom- well. A: Dev AGA, for CGA-\n32-3/7 P: cont dev supportive cares\n#5 PARENT\ns/o: Both arrived separately. EAch speaking kindly\nto infant yet strained between them. Sharp comments to one\nanother. Mom held infant kangaroo style for 1 hr. Mom also\nmet with LC to reinforce BM collection. assisted RN in\nreturning infant to isolette. A:Both live separately\n yet each involved with baby.. Dealing with stressful time.\nP: Cont to support. SW to futher evaluate needs.\n#6 BILI\ns/o: Bili today 4.8/.3-- double phototx decreased to single.\n\nA: Bili dropping. P: cont phototx and repeat with next lab.\n#7 SEPSIS\ns/o: Infant cont on gent and vanco for + Blood Cx. Pre vanco\nlevel--9.3/ post--24.1. NNP aware. Repeat blood cx neg to\ndate. A: r/o sepsis. P:Await final cx results. Gent levels\ntomorrow with 3rd dose.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-12 00:00:00.000", "description": "Report", "row_id": 1788562, "text": "NICU nursing note\n\n\n2. FEN=O/TF cont at 150cc/k/d of BM28PM gavaged over 40min.\nAbd benign. (Please refer to flowsheet for assessment.) No\nspits. Cont on Vit E and iron. Voiding. Sm stoolx1 heme\n(-). A/tolerating current regime. P/cont to monitor for\nfeeding intolerance.\n\n4. G&D=O/Temp stable swaddled now in open crib. Alert and\nactive with cares. Sleeping well between feeds. A/alt in\nG&D. P/cont to monitor and support G&D.\n\n5. =O/No contact with this shift. P/cont\nto support and educate .\n\n8. Resp=O/Cont on NCO2 FIO2 100% 75-100cc/min flow. No\nspells. Cont on caffeine. (Please refer to flowsheet for\nresp assessment.) A/Stable on NCO2. P/Cont to monitor for\nresp distress.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-04 00:00:00.000", "description": "Report", "row_id": 1788657, "text": "NPN 7p7a\n\n\nFEN\nWt 2.290 (+50). PG BM30PM and offered bottle x 1 q shift.\nHave not done yet this shift as she has shown no interest.\nAbd soft, round. AG stable. Trace stool. Asp max 2 cc,\nbenign. No spits. Due for lites on . Vit E, iron and\nKCL supps. Infant toleratign TF. Offer bottle x 1 q shift if\ninterested. Monitor weight and exam.\nG/D\nIn . A/A with cares. Temps stable. MAEs. FS&F. Passed\nhearing screen this shift. AGA. Monitor for milestones and\nsupport G/D.\nParenting\nMom called x 1 early this shift for an update. Asking\nappropiate questions. Complaining of a cold and not sure if\nshe will be in tomorrow. She has a lactation consult\nscheduled and will need to be rescheduled if she is too sick\nto come in. Invested and loving Mom. Support and educate.\nResp\nInfant in NC, 500 cc flow @ 60-75%. LSC. RR 40-60s. Upper\nairway congestion. TB suc for lrg mucus plug of both nares.\nS/C rtxs. Infant with o2 and flow needs. Monitor and support\nresp status.\nCV\nAudable murmur. Precordium quiet and pulses normal. Pale\n. HR 150-160s. BP stable. Mild generalized edema. Last\nlasix on . Infant without CV distress. Monitor and\nsupport cardiac status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-14 00:00:00.000", "description": "Report", "row_id": 1788701, "text": "NPN NOCS\n\n\n2. O: Wt down 5gms. TF at 130cc/kg of BM 30 with PM. Po/Pg\nfeeds. Full feedings gavaged over 50min. residual.\nVoiding and . A: Working on po feeds. P: Continue\nwith plan.\n\n4. O: Temp stable in open crib. and active with cares.\nA: AGA. P: Continue to support dev needs.\n\n5. No contact from .\n\n8. O: Remains in NCO2 500cc at 60-65%. LS clear. Nasal\ncongestion noted. RR 40-60's. A: O2 requirement. P: Continue\nto monitor.\n\n9. Continues with soft murmur. , perfused. VSS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-14 00:00:00.000", "description": "Report", "row_id": 1788702, "text": "Neonatology\nRemains in NCO2 Flow at 500 cc. Fio2 60-70%. Nasal secretions continue. Occasional drifts in sats. Murmur as before\nStarted on diuril sveeral days ago.\n\nWt 2635 down 5. TF at 130 cc/k/d. Taking better po. Abdomen benign.\nLytes to be checked tomorrow. Still req some gavage.,\n\nHct 30 last week.\n\nWill continue current resp monitoring and rx.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-28 00:00:00.000", "description": "Report", "row_id": 1788762, "text": "NPN 1900-0700\n\n\nFEN: Bottles all feeds. TF=130cc/kg/day (restricted), TF\nintake for last 24' 127cc/kg/day. Abdomen benign, good BS.\nVoiding, no stool (glycerin supp given).\n\nG/D: Temps stable swaddled in . A&A w/cares, wakes for\nall feeds, did not sleep well in between cares. slept\nfor a short time in swing, but prefers to be held. AFSF,\nAGA, likes pacificer.\n\n: Mom called X1 for update. Plans to be in for am\ncares.\n\nRESP: NC 200cc RA, Sats 93-97%. LS C/=, mild SCR, mild nasal\nstuffiness.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-28 00:00:00.000", "description": "Report", "row_id": 1788763, "text": "Neonatology Attending\n\nNow day of life 62, CA 3/7 weeks.\nIn 200cc of 21-25% O2 by nasal cannula, RR 40-60s\nO2 sats 93-97%\nHR 150-170s\n\nWt. 3040 up 55gm on 130cc/kg/d - took in 127cc/kg/d of MM28 with Promod\nFeedings well tolerated all po.\nNormal urine output. No stool.\n\nAssessment/plan:\nSteady progress continues - now on all po feedings.\nWill continue with current management.\n\nDischarge teaching in progress.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-28 00:00:00.000", "description": "Report", "row_id": 1788764, "text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. Remains in nasal cannula O2 200cc 21-30%. BS clear and equal with mild subcostal retractions, color pale . RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Normal female genitalia. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-30 00:00:00.000", "description": "Report", "row_id": 1788507, "text": "NICU nursing note\n\n\n1. Resp=O/Cont in room air. Occas sat drifts to 80's.\nCaffeine loading dose given at 1400 r/t ^spells. Spellx3 so\nfar this shift. (Please refer to flowsheet for resp\nassessment and details of A/B's.) A/Stable in room air.\nStarted on caffeine. for ^spells. P/Cont to monitor for\nresp distress.\n\n2. FEN=O/TF increased to 150cc/k/d. Enteral feeds\npresently at 80/k/d of BM20/PE20 gavaged over 25 min.\nRemaining 70cc/k/d=PND10 with lipids via patent/intact PIV R\nhand. Abd full. No loops. Girth stable. 3-5cc asp. Mod\namt of air asp. from stomach at Qcare. Sm spit x2 (one with\nbrady). (Please refer to flowsheet for assessment.)\nVoiding. Mec stoolx2. A/Alt in FEN. P/Cont to monitor for\nfeeding intolerance. Cont to advance enteral feeds 15cc/k\n as tol.\n\n4. G&D=O/Temp stable nested in servo isolette. Alert,\nactive, and irritable with cares. Sleeping in short naps.\nA/Alt in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom in to visit. Updated by this nurse.\nA/appropriate and actively involved. P/cont to support and\neducate .\n\n6. hyperbili=O/Cont under double phototx. Remains\nruddy/jaundiced. A/^bili. P/Cont with current Rx. Obtain\nbili am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-30 00:00:00.000", "description": "Report", "row_id": 1788508, "text": "Fellow note: physical exam\nAlert, active, under phototherapy. RRR S1S2 nl No murmurs Femorals palpabel. Mild retractions. CTAB. soft, NTND BS active. AFOF Tone and power AGA MAEW CR< 2 secs.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-30 00:00:00.000", "description": "Report", "row_id": 1788509, "text": "FEN: On assessment for 5pm feeding 8 cc bilious aspirate removed. a.g. 22.5 soft loops noted. great bowel sounds. NNP evaluated. CBC and BC drawn KUB taken. Per M.D Kub appears wnl and CBC wnl thus far will resume feeding and continue to monitor. Infant has had 3 \" spells\" since caffeine bolus. Irritable at times .Stooled earlier today.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-19 00:00:00.000", "description": "Report", "row_id": 1788590, "text": "NPN \n\n\n\n #2. FEN: Infant conts on TF 150cc/k/d BM 28w/PM (45cc pg'd\nover 40min). Mom put to breast at 1300 cares. Mom has lg\nnipples and is difficult for infant to latch. She made many\nattempts, latched a few times and took few sucks then fell\nasleep. Abd soft w/active Bs, asp, no spits, no loops,\nvoiding and stooled x2 heme-. A: Learning to BF. P: Cont to\nsupport nutritional needs. Encourage BF.\n\n #4. DEV: Temp stable swaddled in OC. Alert and active\nw/cares. Not waking for feeds. Sleeps well between cares.\nMAEW. AF soft and flat. A: AGA P: Cont to support dev needs.\n\n #5 : Both in at 1200 for 1300 cares. Mom changed\ndiaper and did temp change independently. She then BF infant\nw/minimal assistance. took turn holding infant. Updates\non infant's progress given at the bedside. Asking approp\nquestions. A: Involved . P: Cont support, educate and\nkeep updated.\n\n #8. RESP: Infant conts on NC 100% 75-200cc flow. Sating\n89-98%. Req increased flow during feeding and BF w/drifts to\nthe low 80's. LS cl/=. Mild baseline retractions. Conts to\nbe tachypnic 70-90. Conts on caffeine. No spells so far\ntoday. A: Stable in NC w/o spells. O2 req increases\nw/feeding. P: Cont to monitor closley. Document spells.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-20 00:00:00.000", "description": "Report", "row_id": 1788591, "text": "NPN 1900-0700\n\n\n2. F&N: TF remain at 150cc/k/d of BM28 with promod. Feeds\ngavaged in over 45 minutes. Abd benign. BS+. No spits and\nminimal aspirates noted. Voiding and passing small green\nstools with each diaper change. Desitin to reddened\nbuttocks. Weight gain 50 grams.\n\n4. DEV: is active and alert during her cares. Temp\nstable swaddled in open crib. Fontanels are soft and flat.\n\n\n5. PAR: No contact from so far this shift.\n\n8. RESP: Pt remains on low flow nasal cannula, requiring\n75-125cc flow. Sxn for mod thick cloudy secretions X 1.\nWill monitor for results. RR 60-70's. Lung sounds are\nclear. IC/SC retractions. No spells noted.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-20 00:00:00.000", "description": "Report", "row_id": 1788592, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-20 00:00:00.000", "description": "Report", "row_id": 1788593, "text": "Neonatology Attending Note\nDay 23\n\nCGA 34 6\n\nNC 75-125 cc, 100%. Cl and =. Scant secretions. Mild rtxns. RR60-70s. No A&Bs. On caffeine. 73/48, 58. HR 150-170s. No murmur.\n\nWt 1840, up 50. TF 150 cc/k/day BM28 w promod most pg. Abd benign. Nl voiding and .\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with resp insuffieciency. Try off caffeine. Encourage po skills.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-13 00:00:00.000", "description": "Report", "row_id": 1788563, "text": "NNP 7p-7a\n\n\nFEN:\n TF: 150cc/kg/D of /BM 28W/PM. Full volumes are being\ngavaged over 40 mins. Tolerating feeds w/ minimal aspirated\nand minimal spits. Abd is benign w/ active BS. AG is stable.\nInfant is voiding and stooling w/ each diaper chg, heme neg.\nApplying criticade to reddened bottom area w/ each diaper\nchg. Please refer to PT's chart for additional FEN data.\nContinue to monitor and support FEN status.\n\nDEV:\n Pt's temp remains stable while swaddled in OAC. Pt is alert\nand active w/ cares, and sleeps well in between them,\nespecially on her tummy. Irritable at times. Infant settles\nwell by sucking on fingers or pacifier. Continue to monitor\nand encourage developmental milestones.\n\nPAR:\n No contact w/ so far this shift.\n\nRESP:\n Infant remains on NC w/ 75-100cc flow of 100% o2. O2 sats\nare stable. LS: cl/=. Mild sc retrax observed Continues on\ncaffeine. No desats or spells so far this shift. Please\nrefer to P T's chart for additional RESP data. Continue to\n O2 and monitor and support current RESP status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-13 00:00:00.000", "description": "Report", "row_id": 1788564, "text": "Resp\nLungs clear. Breath comf with mild retractions. Drifting to 86-87 on occasion. O2 increased. Baby with nasal cannula and 125cc flow. no true spells. Suctioned nasally with tb syringe for sm to mod amt white secretions. RR40-70's.\nA. Increased O2 requirement\nP. Cont to monitor.\nCV\nColor ruddy. No murmur heard . BP stable.\nFEN\n feeds at 150cc/kg BM28 with promod. small spit. Stool on liquidy side. Diaper area irritated. Critic aid applied and cleansed with mineral oil. HOB elevated. Max asp 4cc.\nA. feed\nP. Cont to monitor to feed\nAgree with above note by coworker.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-13 00:00:00.000", "description": "Report", "row_id": 1788565, "text": "Neonatology Attending\n\nDay 16\n\nRemains on nasal cannula at 75-125 cc/min flow. RR 60-80s. Clear breath sounds. Mild retractions. No bradycardia, murmur. BP mean 52. Weight 1535 gms (+25). On BM 28 with Promod. Small spits. Minimal aspirates. Passing heme negative stool. Stable temperature in open crib.\n\nRespiratory insufficiency continues. Will do cardiac evaluation to rule out small shunt. Will call Cardiology if evaluation is concerning. Monitoring closely. Gaining weight well.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-13 00:00:00.000", "description": "Report", "row_id": 1788566, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in NCO2. Skin ruddy. AFOF. MMM. Good aeration. Lungs CTA bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Brisk cap refill. Abd full, but soft. +BS. Moving all extremities well. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-14 00:00:00.000", "description": "Report", "row_id": 1788703, "text": "NPN 0700-1900\n\n\n2.FEN: Infant remains on TF 130cc/kg/day of BM 30 with\npromod. She is being gavaged via NGT in left nare and being\noffered breast or bottle once per shift. Infant is\ntolerating feeds well, no spits. She had a 4.0cc aspirate\ntoday of non-bilious undigested breastmilk following\nbreastfeeding. Mom breastfed with lactation consultant for\nless than 5 minutes with latch on. Abdomen is soft and\nround, no loops and consistent abdominal girths. She is\nvoiding and . Infant has a moderate amount of\ngeneralized edema, especially noted in both eyes. Infant is\non Diuril, KCL supplements, as well as Fe+ and vitamin E.\nPlan to check electrolytes in the morning and continue to\nmonitor FEN status.\n\n4.DEV: Infant is swaddled in an open crib with stable\ntemps. She is and active with cares, sleepy at times.\n She sucks vigorously on pacifier and brings hands to face.\nContinue to support growth and development.\n\n5.Parenting: Mom in today with grandmother and brother to\nvisit with infant. Mom held infant and was independent in\ncares. Mom unable to visit tomorrow but will be back on\nMonday. Continue to support and keep informed.\n\n8.Resp: Infant remains on NC 500cc of 60-70% Fi02. Lung\nsounds are clear and equal with upper airway congestion.\nInfant was suctioned for a moderate amount of yellow/old\nblood secretions. RR 50s-70s with subcostal retractions.\n02 sats 88-97% with occasional drifts to the low-mid 80s,\nquickly self-resolved. She remains free of spells thus far\nthis shift. Continue to monitor respiratory status and wean\n02 as tolerated.\n\n9.CV: Infant with a persistent soft murmur. Infant is \nand well perfused with normal pulses. BP today 72/36(49)\nand HR 150s-170s. Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-14 00:00:00.000", "description": "Report", "row_id": 1788704, "text": "Student Neonatal Nurse Practitioner Note-PE\nAgree with above PE\n" }, { "category": "Nursing/other", "chartdate": "2195-11-26 00:00:00.000", "description": "Report", "row_id": 1788755, "text": "Neonatology\nIN RA flow of 200 last night. Flow removed last night but to 80s. Will trial again as tolerated in next 24 hours. Continues on diuril\n\nWt 2985. TF at 130 cc/k/d of 28 cal. ABdomen benign. Toleratying feeds well. STill requiring some gavage. Abdomen benign.\n\nAwiating maturation of feeds and resp control.\n\nSpoke to mother on phone yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-26 00:00:00.000", "description": "Report", "row_id": 1788756, "text": "Neonatology - Progress Note\n\n is active with good tone. She is , well perfused, no murmur auscultated. She remains in NCO2 200ccs/21%. Breath sounds clear and equal. Efforts to wean off O2 last night unsuccessful as she was having lingering into mid to low 80's. She is tolerating feeds. PO feeding efforts improving. Abd soft, active bowel sounds, no loops. Voiding and more regularly on prune juice. Stable temp in open crib. Due for 2 month immunizations. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-01 00:00:00.000", "description": "Report", "row_id": 1788510, "text": "NPN Nights\n\n\n#1 Pt received and cont in RA. LS C+=. No spells so\nfar this shift. Pt cont on caffine. P- Will cont to monitor\nresp status.\n#2 FEN- TF=150cc/kg/d. Enteral feeds @ 95cc/kg/d of BM or\nPE20. IV fluids @ 55cc/kg/d of PND10 infusing through PIV.\nIncreasing feeds 15cc/kg/. abd benign. ag- 23-23.5cm\nvoiding. lg green stool after rectal stim given. abd full\nsoft. no spits. 2-4.4cc asp non bilious. P- Will cont to\nmonitor FEN and obtain lytes this am.\n#4 G&D- Temp stable in servo isolette. alert and active with\ncares. sucking on pacifier. rash to diaper area, nystatin\napplied. P- Will cont to monitor G&D.\n#5 parenting- No contact from so far this shift. P-\nWill cont to encourage parental visits and calls.\n#6 Pt cont under double phototherapy. eyeshields\non. Pt ruddy and jaund. P- Will cont to monitor hyperbili\nand obtain bili this am.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-01 00:00:00.000", "description": "Report", "row_id": 1788511, "text": "Neonatology\nIncreased spell frequency yesterday. Remaisn in RA. Started on caffeine.\n\nWt 1260 up 35. TF at 150 Feeds at 95 cc/k/d. Tolereating well via gavage. Abdomen bneign this am. HAd single bilious aspirate yesterday afternoon. KUB unremarkable. Lytes in good range. Will continue feeding advancement with close monitoring of tolerance.\n\nBili in 7 range. Relatively stable under photorx. Will plan recheck on Saturday.\n\nHUS for next week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-07 00:00:00.000", "description": "Report", "row_id": 1788540, "text": "Nursing Progress Note:\n#2 - F&N: TF at 150cc/kilo/day = 34cc's q 4 hours.\nIncreased cals to BM26 today. Tolerating feeds well thus far\nover 45 min. No spits. Minimal aspirates. Girth 21-22cm.\nVoiding and stooling. Fissures noted at rectum. Desitin\napplied to bum with cares.\n\n#4 - DEV: TEmps stable in off isolette. Swaddled. Alert and\nactive with cares. MAE. AFSF. Hx of Normal Head US.\n\n#5 - : No contact thus far today.\n\n#8 - RESP: REmains in low flow NC. Increased O2 50-100cc's\nfrom 25-50cc yesterday. Mild int/sub retractions. No spells\nthus far today. REmains on caffeine. Team Aware.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-07 00:00:00.000", "description": "Report", "row_id": 1788541, "text": "Neonatology Exam:\n\nPE: active infant, AFOF, normal S1S2, no murmur, breath sounds slightly coarse bilaterally, no ic/sc retx. abdomen slightly distended yet soft. ext warm, well perfused. tone aga.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-08 00:00:00.000", "description": "Report", "row_id": 1788542, "text": "npn 1900-0700\n\n\n#2 fen\ntf 150cc/kg of bm26 gavaged q4hours. wt. 1.420 (+40gms). abd\nbenign. voiding and stooling green guiac + with each diaper\nchange. lg fissures noted, some bleeding noted @ 3 and 9\no'clock. ag 20.5-24cm. no spits or aspirates.\n#4 g&d\npt in off isolette swaddled with stable temps. alert and\nactive with cares. maew. fontanelles soft and flat.\n#5 parenting\nno contact thus far this shift.\n#8 resp\npt continues in nc fio2 100% with flow 35-75cc. lsc and\nequal. ic/sc retraction noted. rr 40-60's. tb sux for small\namt thick yellow. no spells thus far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-08 00:00:00.000", "description": "Report", "row_id": 1788543, "text": "Neonatology Attending\n\nDay 11\n\nRemains on nasal cannula- 25-50 cc/min. RR 40-60s. Mild retractions. Occasional drifts. On caffeine. No bradycardia. No murmur. HR 140-160. Weight 1420 gms (+40). On BM 26. Tolerating well. Stable temperature.\n\nMild respiratory insufficiency. Will continue to monitor respiratory status- weaning oxygen as allowed. Gaining weight well. No changes in plan today.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-29 00:00:00.000", "description": "Report", "row_id": 1788631, "text": "0700- NPN\n\n\nRESP: Cont on NC 100% FiO2 75-125cc flow rate (increased to\n200cc while supine for cares/PO feeding). RR 50's-70's, O2\nsats > 89%. LS clear/=. Moderate SC retractions noted. No\nbrady spells. Occasional desats to high 70%'s to low 80%'s\nthat are either self-resolved or require increase in O2. P:\nCont to monitor and wean O2 as tolerated.\n\nCV: Pt cont with soft murmur. HR 160's-170's. See flow\nsheet for BP. Peripheral pulses normal. Cap refill brisk.\nPt , well perfused. P: Cont to monitor murmur.\n\nFEN: TF=130cc/kg/d of BM30 with PM (47cc Q4hr) PO/PG. Pt\nPO fed x 1 this shift, BF for < 5 mins and took 10cc by\nbottle. No spits. Max aspirate of 2.2cc. Abdomen benign.\nPt is voiding, trace stools x 2. Cont on Ferinsol and Vit\nE. P: Cont to monitor feedings/weight and encourage PO\nfeedings as tolerated.\n\nDEV: Temps stable in , pt dressed/swaddled. MAE,\n/active with cares. Sleeps between cares, beginning to\nstir around feeding times. Sucks pacifier and brings hands\nto face for comfort.\n\nPARENTING: Mom in to visit for 1300 care, updated by RN,\nasking appropriate questions. Mom participated in care, BF\nand held infant independently. P: Cont to support/educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-29 00:00:00.000", "description": "Report", "row_id": 1788632, "text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds limited-improved with nasal suctioning. Nl S1S2 grade murmur audible. and well perfsued. Abd benign, no HSM> Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 1788633, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF restricted to 130cc/k/d. Infant to get bm30\nwith promod, 48cc q4h po/pg. Infant took whole bottle x1\ntonight, gavaged the remainder. Infants abdomen is benign,\nvoiding and . No spits, aspirates. Getting\ndesitin to bottom for redness. A: Stable P: Continue to\nmonitor.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive with cares. Stirring before feeds. Sucks on pacifier.\nA: AGA P: Continue to support.\n\n#5 Parenting S/O: No contact. A/P: Unable to assess,\ncontinue to support.\n\n#8 RESP S/O: Infant remains in NC 100% FiO2, 125-200cc\ntonight. Infant lungs are clear, with subcostal retractions.\nRR 60-80's, frequent drifting noted. No spells. A: Stable in\nNC P: Continue to monitor and wean O2 as .\n\n#9 CV S/O: Infant has audible murmer. HR 160-180's, appears\n well perfused. BP tonight 82/44/56. Remains in NC O2.\nA: Stable P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-30 00:00:00.000", "description": "Report", "row_id": 1788634, "text": "Neonatology Attending Note\nExam:\nResting comfortably in open crib. +NC, +NG. AFSF. ?puffy eyes. Lungs cl and = BS. CV RRR, no murmur, 2+FP. Abd soft, +BS. Ext and well perfused.\n\nCXR still bilat hazy lung fields, no pleural effusion, no infiltrates, no assymetries. Cardiothymic silhouette normal.\n\n consider diuretic trial in future if O2 requirment persists and infant is otherwise ready to go home.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-02 00:00:00.000", "description": "Report", "row_id": 1788517, "text": "7 Infant with Potential Sepsis\n\nNursing Progress Note:\n#1 - RESP: Infant remains in room air. Lungs clear and\nequal. Mild intercostal/subcostal retractions. RR (40-60).\nNo spells thus far this shift. Remains on caffeine.\n\n#2 - F&N: TF at 140cc/kilo/day = 32cc's q 4 hours of\nBM/PE20. Tolerating feeds well. One spit this afternoon.\nMinimal aspirates. Girth 20.5 - 21cm. No loops. Soft. +BS.\nVoiding and stooling - bile green stools. PLAN: Increase\nfeeds to 150cc/kilo at 1am. Lytes and Bili on Sunday am.\n\n#4 - G&D: Temps stable on servo. Alert and active with\ncares. MAE. AFSF. Irritable at times. Likes lying on belly.\nSucking on pacifier at times. Head US planned for Monday.\n\n#5 - : in this am. Updated at the bedside. Spoke\nwith mom on the phone this morning updated about sepsis\nissues. Not planning to visit today. Will call later this\nevening.\n\n#6 - BILI: Remains under double phototherapy. Eye shields\non. Working up on feeding. Voiding and stooling. REcheck\nbili on Sunday.\n\n#7 - Sepsis: Blood culture from - growing out G+ cocci\n- pairs and clusters. Sent another Blood culture this am.\nIV placed in scalp. Vanco and gent. Continue to\nmonitor for signs and symptoms of sepsis.\n\n\nREVISIONS TO PATHWAY:\n\n 7 Infant with Potential Sepsis; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-02 00:00:00.000", "description": "Report", "row_id": 1788518, "text": "Fellow note: physical exam\nAlert, active. RRR S1S2 nl No murmurs. Femorals palpable. Mild retractions. CTAB soft, NTND BS active AFOF Tone and power AGA MAEW CR< 2 secs\n" }, { "category": "Nursing/other", "chartdate": "2195-10-03 00:00:00.000", "description": "Report", "row_id": 1788519, "text": "Nursing progress note\n\n\n #1 O: Remains in room air with equal & clear breath sounds\n& mild IC/SC retractions. No A's, B's, or desats. A: Stable\nin room air. P: Cont to assess.\n#2 O: Wgt down 5 gms. Advanced to 150cc/k/d 20 cal BM/PE.Abd\nsoft with active bowel sounds & no loops. Minimal aspirates,\nno spits. Voiding & stooling. Stool was guaiac neg. Baby has\nhep lock in scalp for antibiotics. A: Tolerating feeds. P:\nCont to assess for signs of feeding intolerance.\n#4 O: Remains in servo isolette, nested in sheepskin. Alert\nwith cares. Sucks on pacifier. A: AGA. P: Cont to assess.\n#6 O: Remains under dbl phototherapy with eye patches on. A:\nHyperbili of prematurity. P: Bili to be drawn on Sun AM.\n#7 O: Remains on antibiotics. Most recent blood culture is\npending. Temp is stable. No signs of sepsis. A: Sepsis\nsuspect. P: Antibiotics as ordered. Assess for signs of\nsepsis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-03 00:00:00.000", "description": "Report", "row_id": 1788520, "text": "Neonatology Attending Progress Note\n\nAddendum - PE\nBaby is active breathing comfortably.\nAF soft and flat.\nLungs clear and equal.\nCVS - S1 S2 normal intensity, no murmur\nAbd - soft with no distension\nNeuro - tone good\nMAE well.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-23 00:00:00.000", "description": "Report", "row_id": 1788607, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN NASAL CANNULA O2, 100%, 50-100CC AT\nREST. INCREASED TO 200CC WITH CARES. BABY MUST BE PRONE WHEN\nAT REST. WHEN BABY IS SUPINE OR SIDE LYING SHE DESATS TO\n80'S IN 200CC. RR 70-80'S, WITH MILD INTERCOASTAL/SUBCOASTAL\nRETRACTIONS. BABY LOOKS COMFORTABLE. NO HEAD BOBBING OR\nINCREASED WOB. NO EPISODES OF APNEA OR BRADYCARDIA THIS\nSHIFT. OCCASIONAL DRIFTS IN O2 SATS TO 80'S THAT RESOLVE\nWITH INCREASED O2. NO MURMUR, HR 150-160'S, COLOR . BP\n80/34 48. CXRAY REPEATED THIS AFTERNOON, IS BENIGN. CARDIAC\nECHO DONE AT 5PM, AWAITING RESULTS. BAG PLACED ON BABY TO\nCATCH URINE SPECIMEN TO R/O CMV. CONTINUE TO MONITOR RESP\nSTATUS CLOSELY AND WEAN O2 AS .\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS WELL ON\n150CC/K/D OF BM28 W/PROMOD, 49CC Q4HRS VIA GAVAGE OVER\n50MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 24, ASP.\n1CC. VOIDING AND WELL, STOOL GUIAC NEG. BOTTLE BABY\nAT 9AM FOR 23CC. AT 1PM MOM ATTEMPTED TO BF, BUT BABY WAS\nPASSIVE AND DID NOT LATCH ON. SET UP LACTATION CONSULT\nAPPOINTMENT FOR TUESDAY 1PM. CONTINUE CURRENT FEEDING PLAN.\nMONITOR FOR ANY FEEDING INTOLERANCE. PO FEED ONCE A SHIFT IF\nBABY IS BREATHING COMFORTABLY.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nREPEAT HEAD U/S NEXT WEEK. GIVE HEP B WHEN BABY IS 2K.\nCONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING:MOM IN TO VISIT AT 1PM. SHE IS INDEPENDENT\nWITH CARES. SHE ATTEMPTED TO BF BUT BABY WAS PASSIVE. SHE\nHELD BABY FOR 1HR. UPDATED AT BEDSIDE. CONTINUE TO SUPPORT\nAND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-23 00:00:00.000", "description": "Report", "row_id": 1788608, "text": "NEonatology- PRogress Note\n\nPE: Remains in nasal cannula O2, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V^S, afso,active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2195-10-24 00:00:00.000", "description": "Report", "row_id": 1788609, "text": "2. F/N: O: Infant is on 150cc/k/d of BM 30 + promod, q 4\nhour feeds. She was awake early and bottled at the 9p feed.\nShe took 30cc well before tiring out. Abd is benign, no\nspit, asps. She is voiding and g- stools. She\nlost 15g. A: Mostly gavage but learning to bottle. P:\nContinue w/ plan.\n\n4. G/d: O: Temp is stable in the open crib. Infant is alert\nfor feeds, sleeps well inbetween. A/P: Continue to support\ninfant needs.\n\n5. : No contact so far this shift.\n\n8. Resp: O: Infant continues on the nasal cannulla,\nlow-flow, and at 50-200cc flow. Ls clear, no spells. She\nmanaged to keep her sats up when lying on her R side but was\nunable to on her left. She dramatically improved when placed\nprone. A: Position determines this infant's tolerance. P:\nWean O2 as .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-24 00:00:00.000", "description": "Report", "row_id": 1788610, "text": "Neonatology\nResp remains same as yestreday with increased resp rate, but comfortable. Echo shows no structural heart disease.\n\nWt down 15. Tolerating feeds at 150 cc/k/d of 28 cal. Abdomen benign.\n\nWill monitor resp status closely and detremine need for further eval.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-26 00:00:00.000", "description": "Report", "row_id": 1788757, "text": "NPN 0700-1900\n\n\n#2 O: TF= 130cc/kg/d. Infant taking 65cc's of BM28 with\npromod q 4h via all bottles. Abdomen benign; voiding, no\nstool. Occasional sm spits with burps. Remains on prune\njuice, vit E and iron. A: Tolerating feeds. P: Cont to\nmonitor.\n\n#4 O: Infant maintaining temp in . Awake and with\ncares; sleeping well between. Swaddled in blanket; brings\nhands to face for comfort. Waking on own for feeds. A: AGA.\nP: Cont to support development.\n\n#5 O: Mom called x1 for update. Mom stated she plans to come\nin for 1700 cares and feeding. A: Involved. P: Cont to\nsupport and update.\n\n#8 O: Infant remains in NC o2 200cc's of flow at 21-25% o2.\nRR 30's-60's with mild SC retractions. LS clear and =.\nOccasional nasal stuffiness reported; no suctioning needed\nas yet this shift. Remains on diuril and kcl as ordered. A:\nStable in NC. P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-27 00:00:00.000", "description": "Report", "row_id": 1788758, "text": "NPN 1900-0700\n\n\nFEN: Bottles all feeds, tolerating well, no spits. Abdomen\nbenign, good BS, voiding, no stool - has lots of gas.\n\nG/D: Temps stable swaddled in . A&A w/cares, wakes for\nfeeds. AFSF, soothes well w/pacificer - loves to be held.\n\n: Mom called X1, verbalized sadness regarding \ndoing well w/bottle but poorly at breast. Reassured Mom that\n is still learning to breast feed and that it takes\ntime. Also that the bottle is easier to obtain milk from.\nMom verbalized understanding stating \"Hopefully she'll do\nbetter at home.\" Plans to be in on Saturday.\n\nRESP: NC 200cc FiO2 21-25%. Occasional sat drifts w/QSR. LS\nc/=, congested upper airway. Mild SCR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-27 00:00:00.000", "description": "Report", "row_id": 1788759, "text": "Neonatology\nIn NC flow from 21-40%. Increased with feeds.\n\nWt 2985 no change. Taking feeds at 130 cc/k/d. All po over course of day yesterday, but this am decreased intake so will monitor intake over next several days.\n\nBactroban to be applied to nares for next 5 days for nasal SA colonization. Discussed with mother last night. Also discussed Synagis\n\nWIll plan for pulmonary consult/fu after discharge.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-08 00:00:00.000", "description": "Report", "row_id": 1788544, "text": "2. TF 150cc/k/d BM26 36cc q4h pg over 45 min, abd soft,\npositive bowel sounds, no loops, minimal aspirates, voiding\nand passing stool, desitin applied to diaper area, anal\nfissures visible A: tolerating feedings P: add promod, cont\nto watch for feeding intolerance.\n4. temps stable swaddled in off isolette nested with\nboundaries, active and alert with cares. continue to support\ngrowth and development.\n5. no contact with family so far this shift.\n8. remains on nasal cannula 100% 25-50cc flow, RR40-60, sc\nretractions, BBS equal, clear, no apneas or bradys-on\ncaffeine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-08 00:00:00.000", "description": "Report", "row_id": 1788545, "text": "Fellow note, physical exam\nAlert and active. Breathing comfortably in NCO2. Skin ruddy. AFOF. MMM. Lungs CTA bilaterally. Good aeration. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Good cap refill. Abd soft, nondistended, +BS. Normal female external genitalia. Moving all extremities well. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-18 00:00:00.000", "description": "Report", "row_id": 1788586, "text": "Nursing\n\n\n#2O: On 150cc/kg/d BM28 with promod, q4 hr. feeds. Belly\nsoft, voiding and , . asp. and no spits. Put to\nbreast without much interest.\n#4O: In open crib with stable temp. Likes pacifier and\nbeing held.\n#5O: Mom in took temp and changed diaper nd tried to put\ndaughter to breast. Updated.\n#8O: Nasal cannula in place, 100 5 25 - 50cc in prone\nposition increased in supine position. Br. sounds clear\nwith mild retractions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-19 00:00:00.000", "description": "Report", "row_id": 1788587, "text": "NPN\n\n\n2. Nutritiion: WT=1.790kg, up 30gr. TF 150cc/kg/d of BM28\nw/PM 44cc PG over 40min. No spits, . residuals, abd\nsoft,voiding, trace stoolsx2-heme neg. Buttocks sl red, no\nbreakdown-desitin prn.\nA/P: Tolerating enteral feeds,gaining wt-cont to monitor.\n\n4.G&D: Infant swaddled in crib, mostly in prone position.Not\nalways waking for feeds.\nAwake during cares, settles easily, sleeping in between\ncares-sucks on pacifier. Temps wnl. AFOF, HC 29.5 cm.\nA/P: AGA, cont. to promote growth and development.\n\n5.Parenting: No contact so far this shift.\n\n8.Resp: Remains in NC 75-125cc, mostly in 100cc. BBS clear\nwith mild SC/IC retractions. Increased nasal congestion\nnoted, sxn nares for thick white sxns. RR=40-90's, noted to\nhave increased tachypnea after feeds. No spells on caffeine.\nA/P: Infant continues w/residual 02 requirement from CLD.\nMonitor closley for increased WOB, adjust 02\nrequirement-wean as tolerated. Monitor for increased nasal\ncongestion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-19 00:00:00.000", "description": "Report", "row_id": 1788588, "text": "Neonatology-NNP Physical Exam\n\nInfant remains on NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-19 00:00:00.000", "description": "Report", "row_id": 1788589, "text": "Neonatology Attending\n\nDay 22\n\nRemains on nasal cannula- 25-125 cc/ flow. Mild retractions. RR 50-90s. On caffeine. No murmur. HR 150-180s. BP mean 42. Weight 1790 gms (+30). TF at 150 cc/kg/d- BM 28 with Promod. Gavage feeds. Stable temperature in open crib.\n\nMild respiratory insufficiency continues. Monitoring and weaning oxygen. Gaining weight well. Attempting to po feed.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-07 00:00:00.000", "description": "Report", "row_id": 1788672, "text": "2. TF 130cc/k/d BM30 with promod 53ccq4h, alt po/pg, abd\nstable, minimal aspirates, voiding and passing stool.\n4. temps stable swaddled in open crib, active and with\ncares.\n5. Mom in for 1300 and 1700 feedings, put to breast\nand said she latched on and nursed well, met with LC P:\ncontinue to offer support and provide updates.\n8. remains in 400cc 80%O2 nasal cannula, RR50-70, sc\nretractions, clear and equal, no spells.\n9. murmur audible, color pale-, HR 150-160.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-08 00:00:00.000", "description": "Report", "row_id": 1788673, "text": "NPN\n\n#2 S. O. Weight up 45 grams. Voiding and . Infant\nremains on 130cc/kg/day of breast milk 30 cal with promod.\nInfant continues on an alternating po/pg feeding schedule.\nInfant took half of feed po at the 0100 care. A. Working\non po feeds. P. Continue to assess.\n\n#5 S. O. Mom called x 1 for an update. A. Invested mother.\n P. Support and keep updated.\n\n#8 S. O. Received infant on a nasal cannula with fio2 at\n80% at 400cc of flow. Breath sounds clear and equal.\nSuctioned nares x 1. A. Infant requiring some resp.\nsupport. P. Continue to assess.\n\n#9 S. O. Murmur present. Bp wnl A. hx of murmur. P.\nMonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-08 00:00:00.000", "description": "Report", "row_id": 1788674, "text": "NICU Attending Note\n\nDOL # 42 = 37 5/7 weeks CGA with CLD, learning to PO feed.\n\nFull Rivers\n\nCVR/RESP: soft baseline murmur (samll PDA by echo) NCO2, 75-80% FiO2, 400 cc/ flow,\n\nFEN: Slight dependant edema, abd benign, weight up 45 gm to 2475 gm, on TF of 130 cc/kg/d, MM 30 with PM, about half PO, rest PG. Chronic high HCO3- of unclear etiology, lytes tomorrow.\n\nHEME: Hct 47 on , now looks pale. Will check hct and retic with lyes tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-08 00:00:00.000", "description": "Report", "row_id": 1788675, "text": "Neonatology - PRogress Note\n\nInfant is active with good tone. AfOF. She is , well perfused, soft murmur auscultated. She is comfortable in low flow NCO2. Breath sounds clear and equal. she is tolerating po/pg feeds. Abd soft, active bowel sounds, no loops. Voiding and . Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-18 00:00:00.000", "description": "Report", "row_id": 1788719, "text": "Clinical Nutrition\nO:\n~39 wk CGA BG on DOL 52.\nWt: 2715 g (+50)(~25th %ile); birth wt: 1370 g. Average wt gain over past wk ~12 g/d.\nHC: 33 cm (~25th to 50th %ile); last: 33 cm\nLN: 46.5 cm (~25th %ile); last: 43.5 cm\nMeds include Fe and Vit E, Diuril and KCl.\n noted.\nNutrition: 130 cc/kg/d BM 30 w/ promod, po/pg. Infant takes ~ to full volume when po feeds. Average of past 3 d intake ~127 cc/kg/d, providing ~127 kcal/kg/d and ~3.5 g pro/kg/d.\nGI: Abdomen benign. Team is questioning reflux; possible Ba swallow next week if O2 reqs are not decreased w/ continued diuril threrapy.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is not meeting recommended ~20 to 35 g/d for wt gain or ~0.5 to 1 cm/wk for HC gain. Will continue w/ current feeding regimen for now and monitor future trends. Infant is maintaining her position on wt gain growth curve, so increased kcals are not warranted at this time. LN gain is exceeding recommended ~1 cm/wk, but question accuracy of measurements. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-22 00:00:00.000", "description": "Report", "row_id": 1788735, "text": "Attending Note\nDay of life 56 CGA 39 \nRR Nasal cannula 500 cc of\n50-60% FiO2 no brady\non diuril\nHR 140-160 86/35 mean 54\nperiobidal edema\n2870 up 60 on 130 BM 30 with promod\npo/pg\nno spits no asp last stool friday\ndoes not wake for feeds\non oral nystatin and nystatin\nfor diaper area but rash gone\nfor three days\n\nPlan to stop nystatin to diaper\narea\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788557, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in nasal cannula 100% requiring 150-175cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. CXR(babygram done) and read\nby Dr. .\nA: Still moderate O2 requirement.\nP: Support adequate ventilation.\n\nNUTRITION\nO: Infant continues to spit sm-mod yellow. Feeding tube\nposition changed and aspirates are non-bilious. Babygram\ndone and read by Dr. . Abd soft, full, no loops.\nBowel sounds active. Voiding and passing heme neg stool.\nRemains on TF 150cc/kg/day of 28BM with PM by gavage.\nA: Potential for intolerance of feeds.\nP: Assess closely. Extend feeding infusion time.\n\nPARENTING\nO: No contact with so far this shift. in for\nlast evening's 1700 care time. Independent in temp taking\nand diaper change. Held infant for long period. Updated\nregarding infant's status and plan of care.\nA: Involved parent.\nP: Support and keep informed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788558, "text": "NICU Nursing Addendum\n\nPARENTING\nO: Mom, and sibling in to visit. Mom independent in temp taking and diaper change. Updated regarding infant's status and plan of care. Mom held infant for 1 hour. Is pumping with good success. Is doubtful she will be able to visit tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-12 00:00:00.000", "description": "Report", "row_id": 1788559, "text": "NPN NOCS\n\n\n2. O: Wt 1510, down 5 gms. TF at 150cc/kg of BM28 with PM.\nGavaged over 40min. No spits. No residual. Abd. benign.\nVoiding and stooling. Desitin/vit D applied to reddened\ndiaper area. A: feeds. P: Continue with plan.\n\n4. O: Alert and active with cares. Temp stable in off\nisolette. A: AGA. P: Continue to support dev needs.\n\n5. No contact from .\n\n8. O: Continues on NC 100% at 50-75cc. LS clear. No spells.\nA: Decrease O2 requirement tonight. P: Continue to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-12 00:00:00.000", "description": "Report", "row_id": 1788560, "text": "Neonatology Attending\n\nDay 15\n\nRemains on nasal cannula at 50-100 cc/min flow. Clear breath sounds. RR 50-60s. No murmur. BP mean 48. HR 150-160s. , well-perfused. Weight down 5 gms. On BM 28 with Promod. Had green aspirate yesterday thought to be related to NGT position after KUB. Stable temperature in off incubator. Moved to crib.\n\nMild respiratory insufficiency continues. Will continue to monitor closely. Gaining weight well overall. No change in plan for today.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-12 00:00:00.000", "description": "Report", "row_id": 1788561, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in NCO2. Skin ruddy. AFOF. MMM. Good aeration. Clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Good cap refill. Abd full, but soft. +BS. No HSM. Normal female. Moving all extremities well. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788649, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF,sutures opposed, tongue protruding while at rest\nmild subcostal retrations in NCO2, lungs clear/=\nRRR,no murmur, and well perfused\nabdomen soft, nontender,nondistended, active bowel sounds\nperiorbital edema, and pretibial edema\ngeneralized decreased tone, but tone LE>UE, no clonus\nquiet with exam but desated.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788650, "text": "Nursing Progress Note 0700-1500\n\n\n2. FEN O/A TF=130cc/kg/day of BM30w/PM. PO feeding 1X\nshift. PO fed at 0900, took 20cc, remainder gavaged. \nfeeds well. No spits thus far. asp thus far. Belly\nsoft, no loops. Inf voiding, trace stool 2X. P cont to\nassess FEN needs, UA to be sent, lytes in AM, Renal US\nprobably tomorrow.\n4. DEV O/A Temp stable in . Quietly A/A w/cares,\nSleeping well between cares. P cont to assess dev needs.\n5. O/A Mom spoke with this AM for\nupdates. P cont to support.\n8. REsp O/A Rec'd inf in low flow NC. Inf currently in\nhi flow 500cc 50-60%. Drifts and greatly improved\nbut still present. Lasix d/c'd today. P Art gas in AM, KCl\nto start today.\n9. CV O/A Int soft murm. Baby is well perfused. P\ncont to assess.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788651, "text": " Addendum\nMother updated by phone regarding changes in plan of care made today:\n1. High flow O2\n2. Kcl supplementation\n3. Renal ultrasound tomorrow\n4. Following of electrolytes\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788652, "text": "NPN\n\n\n#2F/N O-Infant remains on BM30calw/promod at 130cc/kg.\nGavages given over 40 minutes. No spits or aspirates noted.\nInfant voidng well and passing soft green stool. Wt. 2240 up\n50gms. Mild edema noted eyes/feet. Started on kCL as\nordered. UA sent. A-. feeds P-Check art. gas lytes\ntonight.\n#4Dev. No change.\n#5Family No contact during shift.\n#8Resp O- Infant remains in NC 1/2L 65-70% O2 to maintain\nsats 92-96. RR 40-70. Mild to moderate subcostal retractions\nnoted. Color pale/. Breath sounds clear. Mild edema\nnoted eyes/ feet. Murmur audible. Occassional spontaneous\n noted to 70's. Infant did respond with increases in\nFIO2. A-Labile O2 requirement P- Follow closely. Check ABG\nas ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-03 00:00:00.000", "description": "Report", "row_id": 1788653, "text": "NPN:\n\nRESP: NC-500cc/ 65-70% 02. Sats 92-97%. RR=50-60 w/SC retraction. BBS =/clear. Upper airway congestion -> sx'd x 1 w/TB syringe for mucus plugs.\n\nCV: No murmur audible. HR=150-160's/ BP=66/30 (46). Color w/good perfusion. Mild generalized edema.\n\nFEN: Wt=2240g (+ 50g). TF=130cc/kg/d; 49cc BM-30 w/promodd q 4 h via NG/PG. Bottled x 1 for 19cc; tolerated well w/o additional 02. Abd benign. Voiding ; green stool. Vit E, FeS04, KCl supps.\n\n: Elec: 137/ 5.0/ 93/ 40. BUN=18; Creat=0.3. To report results to .\n\nG&D: CGA=36 wk. Temp stable in crib. Active and w/cares. Resting well. Swaddled and nested.\n\nSOCIAL: Mother called x 1 for update.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-13 00:00:00.000", "description": "Report", "row_id": 1788696, "text": "Agrees with charting and asessments on 2121. RN\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788504, "text": "NPN 0700-1900\n\n3 Possible Sepsis\n\n1. Resp: Infant remains in RA, maintaining her o2 sats\nbetween 90-95%. Lung sounds clear/=. RR 30-60's. Mild\nIC/SCR noted. 2 spells noted this shift - please see\nflowsheet for further details. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: TF were increased to 140 cc/kg/day. IV fluids are\ncurrerntly at 75 cc/kg of PND10 and IL running through a\npatent PIV without incidence. Ent feedings of PE20 are\ncurrently at 65 cc/kg/day, and are being advanced by 15\ncc/kg/ at 05/17. Tolerating feedings well; abd exam\nbenign, no spits, and AG stable. Max asp 2.8, benign. UO\nfor past 12 hours has been 3.0 cc/kg/hr. Sm mec stool\nnoted. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in betewen cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. : Mom and up to visit. Mom held -\nloving interaction. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Hyperbili: Infant remains under double photo with eye\nshields in place. Bili this am was 7.1. Infant remains\nruddy/jaundiced. P: Cont. to monitor.\n\n6. I/D: CBC benign, BC neg. No overt s/s of infection\nnoted. Problem resolved.\n\nREVISIONS TO PATHWAY:\n\n 3 Possible Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-30 00:00:00.000", "description": "Report", "row_id": 1788505, "text": "NPN\n\n\n#1-O: Remains in RA , sats 90's, clear and equal, RR 40's -\n60's, pink/ruddy, well- perfused, had 2 mild brady's. mild\nto QSR. , no murmur audible.\n\n#2-O: On tf 140cc/k/d, enteral feeds at 80cc/k/d = 18cc\nBM20/PE20 q 4 hrs PG tol wel, min aspirates, no spits, abd\nfull but soft , active bowel sounds, voiding and stooling\nsm- mod mec. d/s = 94 IVF at 60cc/k/d IL and PN D10 as\nordred. increasing enteral feeds by 15cc/k/d as tol cont to\nmonitor.\n\n#6-O; remains under double photo, bili pending this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-30 00:00:00.000", "description": "Report", "row_id": 1788506, "text": "Neonatology\nDoing well. RA. Comfortable appearing. No murmur.\n\nWt 1225 down 60 TF at 140 cc/k/d. Abdomen benign. Feeds at 80 cc/k/d being tolerated via gavage. Will advance tf to 150 cc/k/d and continue feed advancement as tolerated.\n\nHct 62 this am.\n\nBili in 7 range. Under intensive phototherapy. WIll follow.\n\nTemp stable in isollette\n\n for one week.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 1788628, "text": "NPN 0700-\n\n9 Alt in CV\n\n2. TF restricted at 130cc/k/d. Calories advanced to\nBM30PM. Abd benign. Voiding and heme negative stool x2.\nAll gavage feeds at this time; infant not showing signs of\nrooting or interest in bottle. O2 requirement up to 200cc\nflow today as well. Tolerating NGT feeds without aspirate\nor emesis. Will attempt PO feed if infant is interested and\nO2 requirement decreased. Cont to monitor tolerance to\nfeeds and ability to take bottles.\n\n4. Temps stable swaddled in OC. Infant awake and \nwith cares, resting well inbetween. HUS done today. MAE.\nCont to promote development.\n\n5. Mother called and updated on plan of care. Mother\nstated that she has a sore throat and will not visit today.\nCont to support and update .\n\n8. Remains in NC, 100% and 125-200cc flow. Lungs clear\nwith upper airway congestion. Suction nares x2 for small to\nmoderate cloudy secretions. RR 40-70's with occassional\ntachypnea. Mild SC retractions noted. Desat to 75% with\nmorning cares and cont. to have occassional desats to 80's.\nNo A&B's thus far. Increase in O2 requirement from last\nnight- see flowsheet for details. Cont to monitor resp.\nstatus closely and support as needed.\n\n9. Infant with soft intermittent murmur heard this morning.\nHR 150-170. Color , 2+PP, brisk cap refill. See\nflowshet for BP. Cardiology reconsulted for ?PDA. Cont to\nmonitor for further hemodynamic instability- further O2\nrequirement.\n\nREVISIONS TO PATHWAY:\n\n 9 Alt in CV; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-29 00:00:00.000", "description": "Report", "row_id": 1788629, "text": "Nursing\n\n\n#2O: Wt. up 65g on 130cc/kg of BM30 with promod, q 4 hr.\nfeeds. Belly soft voiding and , . asp. and no\nspits. Bottled very well x 1 otherwise gav. fed.\n#4O: with cares, temp stable in open crib.\n#5O: No contact.\n#8O: O2 req. via nasal cannula 100% 75 - 200cc, increased\nwith cares. Br. sounds are clear with retractions, does have\nupper airway stuffiness, sx x 1 for sm. amt. secretions.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-29 00:00:00.000", "description": "Report", "row_id": 1788630, "text": "Neonatology Attending Note\nDay 32\n\nCGA 36 2\n\nNC 75cc-200cc, 100%. RR40-70s. Cl and +BS. Int/sc rtxns. No bradys. Int soft murmur. HR 150-170s. BP 60/43, 49. and well perfused.\n\nWt 2155, up 65 gms. TF 130 cc/k/day BM30 w promod po/pg. well. Nl voiding and .\n\nOn fe and Vit E.\n\nIn open crib.\n\n1 month HUS normal.\n\nA/P:\n - resolving pulmonary process, wean O2 as tolerated\n - no change to nutritional management\n - immature feeding skills, con't to encourage po abilities\n" }, { "category": "Nursing/other", "chartdate": "2195-11-06 00:00:00.000", "description": "Report", "row_id": 1788667, "text": "Neonatology- Physical Exam\n\n remains in NC 500cc. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-18 00:00:00.000", "description": "Report", "row_id": 1788720, "text": "0700- NPN\n\n\nRESP: Cont on NC 500cc 45-55%. RR 40's-50's, O2 sats\n88-94%. LS clear/=. Mild SC retractions. No A/B spells.\nOccasional drifts in O2 sats 80%'s that are either QSR or\nrequire increase in O2. On Diuril. P: Cont to monitor and\nwean O2 as tolerated.\n\nCV: Cont with soft murmur. HR 140's-160's. Peripheral\npulses normal. Cap refill brisk. See flow sheet for BP.\nPt is , well perfused. P: Cont to monitor.\n\nFEN: TF=130cc/kg/d of BM30 with PM (59cc Q4hr) PO/PG. Pt\nbottlefed x 1, taking 59cc PO. Pt breastfed x 1, did well\nfor 30 mins. Small spit x 1. Minimal aspirates. Abdomen\nbenign. Pt is voiding, trace stool x 1. Cont on Ferinsol,\nVit E, KCl. P: Cont to monitor and encourage PO feeding.\nCheck lytes in AM.\n\nDEV: Temps stable in , pt dressed/swaddled. MAE,\n/active with cares. Sleeps between cares, not waking\nindependently for feeds this shift. Sucks pacifier and\nbrings hands to face for comfort. Fontanels soft/flat.\nCont on Nystatin oral for Thrush. AGA. P: Cont to support\ngrowth and development and Thrush.\n\nPARENTING: Both in to visit this shift,\nparticipated in care, asking appropriate questions. \nupdated by RN. Family is loving and invested. P: Cont to\nsupport/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-02 00:00:00.000", "description": "Report", "row_id": 1788780, "text": "Case Management Note\n VNA referral has been postponed as baby not med ready for home d'c. VNA can be called again when d'c date is confirmed . I will follow\n" }, { "category": "Nursing/other", "chartdate": "2195-12-02 00:00:00.000", "description": "Report", "row_id": 1788781, "text": "Neonatology\nRemains in RA. Comfortable appearing. Had several (one a slow as 65 with feeds) as well as brady to 80 yetserday. In conjunction with inavbility to tolerate car seat these suggest continued immatutiy of cardioresp control. WIll await 5 spell free days.\n\nWt 3060 down 55. Tolerating feeds except as noted above. Abdomen benign.\n\nDiuril and KCl script given yesterday.\n\nSpoke with mother via phone this am. She will be in this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-02 00:00:00.000", "description": "Report", "row_id": 1788782, "text": "NPN 0700-1900\n\n\n#2 FEN\nO: TF=130cc/kg/day of BM26 with Enfamil Powder=67cc\nq4hr. Infant took 50cc at 0900 and 55cc and BF at 1300. No\nspits. V/S. Abdomen benign. Active bowel sounds. A:\nTolerating feeds. P: Cont to monitor.\n#4 DEV\nO: Infant remains in . Swaddled. Temp stable. Wakes for\nfeeds. A/A with cares. Sucks on pacifier. Applying desitin\nto bottom. Sleeps well in between cares. A: AGA P: Cont to\nmonitor and support G&D.\n#5 Parenting\nO: Mom in for 1pm cares. Updated by RN and MD. BF and bottle\nfed infant. A: Involved, loving. P: Cont to support and\nupdate.\n#8 RESP\nO: Infant remains in RA. RR=40-60's. O2 sats=91-100%. Mild\nSC retractions. LS are clr/=. No A/B's thus far. A: Stable\nin RA. P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-02 00:00:00.000", "description": "Report", "row_id": 1788783, "text": "Agree with above note by PCA with following addendum: Dr. in to speak with mom re: infant's status. Mom a bit teary with knowledge that infant will not go home today but was reassured of her stable status, just that more time is needed for her to mature. Mom rec'd KCL oral solution via prescription but concerntraion is different so med teaching is necessary. Con't to teach/support.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-09 00:00:00.000", "description": "Report", "row_id": 1788682, "text": "Nursing Note\n\n\n#2O: Fluids at 1130cc/kg, BM30 with promod, q 4 hr. feeds.\nBottled well x 1, gav. x 1, . asp. , no spits. belly\nsoft, voiding, no stool.\n#4O: with cares, temp stable in open crib.\n#5O: Mom called and will visit for 17:00 cares, .\nUpdated on daughter and current plan. Would like to speak\nwith the Dr. she visits .\n#8: Nasal cannula in place 60 - 70% 500 cc, increase with\ncares, less lability noted. br. sounds are clear but does\nhave nasal congestion; sx x 1 with Tb syringe for mod white\nsecretions on left and bloody secretions on right at the end\nof sx.\n#9O: Soft murmur heard x 1 .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-10 00:00:00.000", "description": "Report", "row_id": 1788683, "text": "NPN\n\n\n#2 TF 130cc/k/d of BM30 with promod=56cc q4hrs on pump over\n50 . Abd soft, +BS, no loops. No spits, asp.\nInfant did not bottle overnight d/t tachypnea. Wt\n2565(+70gms). Voiding, small stool.\n\n#4 Infant active and with cares. Occasionally waking\non own for feedings. Sucks on pacifier. Temp stable\nswddled in open crib.\n\n#5 No contact from so far overnight.\n\n#8 Infant remains in NC 500cc/60-70%. RR 60-80's with\nmild-mod SCR. BS clear and equal with upper airway\ncongestion. Nares suctioned x1 for mod white secretions.\nInfant appears most comfortable when placed prone.\n\n#9 Infant pale/. HR 160-170. +murmur heard. BP 86/31\n49.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-10 00:00:00.000", "description": "Report", "row_id": 1788684, "text": "Neonatology\nIncreased to 500 cc flow last night. Subsequently sl decrease WOB and variability in sats. Will consider diuretic rx in coming days. WIll recheck lytes end of eek. Murmur as bfeore. COntinues with mild to mod retractions. Generally comfortable appearing at rest when seen by me this am.\n\nWt 2565 up 70. Abdomen benign. TF at 130 cc/k/d of 30 cal. Abdomen bneign.\nTemp stable in open crib.\n\nWill plan to meet with family tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-22 00:00:00.000", "description": "Report", "row_id": 1788736, "text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. Remains in nasal cannula O2 500cc 50-60%. BS clear and equal with mild subcostal retractions, color pale . Soft murmur on auscultation, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes, no obvious thrush in mouth. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-22 00:00:00.000", "description": "Report", "row_id": 1788737, "text": "0700- NPN\\\n\n\nResp: NC 500cc 40-55%. RR 30-50's. LS clear/=. Mild SC\nretractions. No A/B spells. Occasional drifts in O2 sats\nto 80%'s. On Diuril.\n\nFEN: TF=130cc/kg/d of BM30 with PM PO/PG. Pt bottlefed\nx1,taking 20cc. No spits. Minimal aspirates. Abdomen\nbenign. Voiding, lg stool x1. On Fe, Vit E, KCl.\n\nDEV: Temps stable in . /active with cares. Sleeps\nbetween cares. Sucks pacifier and brings hands to face for\ncomfort. Fontanels soft/flat. AGA.\n\nPARENTING: Mom called x1, updated by RN, asking appropriate\nquestions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-23 00:00:00.000", "description": "Report", "row_id": 1788738, "text": "NPN\n\n\n#2\nInfant remains on TF=130cc/k of BM30 with promad q4 hours.\nInfant has bottled ~half her volume tonight and has\ntolerated the remainder via gavage. Infant has not had any\nspits and only small aspirates. Abd is soft and round. Wt\nis up 60gms-2930.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nTemp has been stable. Infant has been waking for feeds and\nlooking for her pacifier. Sleeps well between cares. Plan\nfor eye exam this am.\n\n#5\nMom called x1 last evening for an update.\n\n#8/#9\nInfant remains in N/C 500cc flow; 50-60% tonight maintaining\nsats low 90s. BS clear= with mild retractions. Nares\nsuctioned x1 for a small amout of yellow secretions. Drifts\nin sats noted; no episodes of bradycardia. Color is ;\nmurmer remains audible.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-23 00:00:00.000", "description": "Report", "row_id": 1788739, "text": "Neonatology- PRogress Note\n\nPE: Reamins in her open crib in nasal cannula O2, with upper nasal secretions audible,gavage tube in place, pale, , bbs cl=, soft systolyc murmur, pulses 2+=, abd soft, nontender, full V&S, afso, active with care\n\nSee attening note for plan\n" }, { "category": "Nursing/other", "chartdate": "2195-11-23 00:00:00.000", "description": "Report", "row_id": 1788740, "text": "Neonatology\nDoing well. Weaned to 200 cc flow NCo2. WIll monitor tolerance. WOB remains decreased. On diuril.\n\nWt 2930 up 60. TF at 130 cc/k/d of 30 cal. Poing well. Abdomen benign. Tolerating feeds. Still requring gavage.\n\nContinue to monitor resp status.\n\nEye exam mature today.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-01 00:00:00.000", "description": "Report", "row_id": 1788512, "text": "#1 - RESP: Remains in room air. Lungs clear and equal. Mild\nretractions. RR(40-60). No spells. Occassional drift in\nO2Sat after crying with self resolve. Remains on caffeine as\nordered.\n\n#2 - F&N: TF at 150cc/kilo/day. Working up on feeds. IVF\ncurrently at 40cc/kilo/day of PN (D10). At 1330pm -\nincreased ENteral feeds to 110cc/kilo/day = 25cc's q4 hours\nof BM20. Abdomin soft and full. +BS. Voiding and stooling -\ndark green soft stool - guaic neg. Increasing feeds by\n15cc/kilo . Lytes and bili on Sat am.\n\n#4 - DEV: Temps stable in servo isolette. Alert and active\ncares. Irritable at times. Enjoys pacifier. MAE. AFSF.\nSutures overriding.\n\n#5 - : Mom in this am - updated at the bedside. Being\ndischarged this evening. Family meeting this afternoon with\nfather. planning to hold this evening prior to\ndischarge.\n\n#6 - BILI: Remains under double phototherapy. Eye shield on.\n BIli this am - 7.1/0.3 down from yesterday 7.6/0.3.\nVoiding and stooling dark green. Working up on feeds. Bili\non Sat. am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-01 00:00:00.000", "description": "Report", "row_id": 1788513, "text": "Fellow note: physical exam\nAlert, active Under phototherapy. In RA Mild retractions. CTAb RRR S1S2 nl No murmurs Femorals palpable soft, NTND BS active AFOF Tone and power AGA MAEW Cr< 2 secs\n" }, { "category": "Nursing/other", "chartdate": "2195-10-01 00:00:00.000", "description": "Report", "row_id": 1788514, "text": "Rehab/OT\n\nMet mom at the bedside. Introduced the role of OT, developmental care, and OT schedule. Will follow up next week for care plan. Infant being held, unavailable.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-02 00:00:00.000", "description": "Report", "row_id": 1788515, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains in RA; maintaining O2 sats >93%. RR\n40-70s, LS clear/=, mild ic/sc rtxns. No spells/desats noted\nthus far tonight. Caffeine dose switched from IV to po/pg.\nP: Cont to monitor resp status.\n\nFEN O/A: Birth Wt: 1370, Current Wt: 1295, ^35g. Received on\nTF of 150cc/k/d. PIV in left foot infiltrated & IVF d/c'd @\n0100 by NNP Buck. Enteral feeds currently @ 125cc/k/d;\nBM/PE20. Infant now receives 29cc q4h po/pg. D-stick 63.\nAbdomen soft/round, active BS. Max asp .8cc. Voiding/trace\nstooling. Nystatin applied to rash on Abd & groin. P: Cont\nto advance enteral feeds 15cc/k/d to 150 total as tolerated.\n\nDEV O/A: Nested on sheepskin in a servo isolette. Temp\ninitially high (99.9), but resolved (98.3) overnight. A/A\nwith cares. Likes pacifier. Settles well with containment.\nP: Cont to support developmental needs.\n\nPAR: No contact from thus far tonight.\n\nBILI O/A: Infant remains under double phototherapy. Appears\nruddy/jaundice. P: Cont to monitor.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-02 00:00:00.000", "description": "Report", "row_id": 1788516, "text": "Neonatology\nRA. no spells. COmfortabel apeparing\n\nWt 1295 up 35. TF at 125 cc/k/d of enteral feeds. IV out.\nAbdomen benign. Continue current enteral feeds.\n\n\n\nBC from 24th groing g+ cocci in pairs and clusetrs. WIll repeat BC and start vanco and gent. ? whether this represents contaminant.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788602, "text": "Clinical Nutrition\nO:\n35 wk CGA BG on DOL 25.\nWT: 1905g(+40)(10-25%ile); Birth WT: 1370g. Average WT gain over past wk ~19g/kg/d.\nHC: 29.5cm(10-25%ile); last wk: 28.5cm\nLN: 40.5cm(<10%ile); Last wk: 42cm\nMeds include: Fe, Vit.E, & lasix x1\nlabs: noted\nNutrition: 150cc/kg/d as BM 28 w/promod, all pg. Average of past 3d intake ~150cc/kg/d, providing ~140kcals/kg/d and ~4.1g pro/kg/d.\nGI: abdomen benign, x1 small spit.\n\nA/Goals:\nTolerating feeds without GI problems except spit as noted above. Infant trialed on breast feeding yesterday but did not do well, currently, feeds are all pg. Labs noted and are within acceptable ranges. Current feeds & supps meeting recommendations for kcals/pro/vits/mins. Growth is meeting recs for WT gain & HC gain. LN shows loss over past week, ? accuracy of measurements. Will follow long term trends. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788603, "text": "2. TF 150cc/k/d BM28 with promod 48cc pg q4h over 50 ,\nabd soft, active bowel sounds, no loops, no spits, minimal\naspirates, voiding and passing stool A: tolerating feedings\nP: continue present care.\n4. temps stable swaddled in open crib, active and alert with\ncares, HUS(1 month) next wk. continue to follow growth and\ndevelopment.\n5. Mom here for 1300 feeding, put baby to breast, pumping\nbreast milk, now back to work. continue to provide updates\nand offer support.\n8. remains on nasal cannula 50-200cc flow 100% sats 81-100\nvery labile, suctioned nasally for mod cloudy secretions,\nRR40-90's, mod sc retractions, BBS fairly clear, equal.\ncolor but mottles easily. P: check ABG, cbc, blood\nculture and 4 ext BP's.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788604, "text": "addendum to above note: ABG 7.48/pO2 43/ pCO2 48/37/+10, MD aware. cardiology here for consult, plan to ECHO baby . 4 pt ; LA 75/37 51, RA 60/35 49, RL 60/30 40, LL 58/29 42. cbc and blood cultures sent. DS 80.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-23 00:00:00.000", "description": "Report", "row_id": 1788605, "text": "NPN\n\n\n#2FEN:\no; Wt 1.945(+40 gms) On 150cc/k/d BM 28 with prom. mostly\ngavage fed. Bottled X1, did fairly well and took most of\nfeed. Abd. soft, active BS, no loops. Voiding qs, urine sent\nfor metabolic labs, passed small yellow stool.\nA: Adequate intake for growth. Improved bottling effort\nP: Cont to feed per plan.\n\n#4dev:\nO: temps stable in oc. alert and active with cares, MAE.\nA/p: Cont to support dev.\n\n#5Parenting:\no: No contact this shift\n\n#8resp;\nO: Remians in NC cannula 100% 13-50cc at rest, incresing to\n125cc for activity. RR 40-60, occasional 80-90, mild sc\nretractions.no spells\nA/P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-23 00:00:00.000", "description": "Report", "row_id": 1788606, "text": "Neonatology\nIncreased FIO2 needs noted over previous days. Remains extremely comfortable apeparing, but tachypneic. CXR hazy. To be repeated. Seen by cardiology team. Will have echo this am.\n\nWt up to . Tolerating feeds at 150 cc/k/d of 28 cal. Taking po reasonably well.\n\nUrine lytes notable for low NA and pH 6. Raises ? of hyperaldo state. Will fololow for now.\n\nWIll send urine CMV.\n\nFOllow course.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-13 00:00:00.000", "description": "Report", "row_id": 1788697, "text": "2. FEN O:Abdomen soft and round with +BS x4 quads.\nAssessment unremarkable. Remains on TF restriction of\n130cc/kg/day= 58cc BM30 with PM q4. Voiding and stooled X1\nguiac neg. Nippled well x1, taking feeds in less than 10\n. Desitin applied to buttocks. No skin breakdown noted.\nWGT: 2.640 down 30g. A: Tolerating feeds. Nippled well\nat 0500. P: Encourage PO feeds. Monitor daily weights.\nMonitor for feeding intolerance.\n2. G&D O: A/A with handling. Sleeping comfortably\nbetween cares. Temp wnl in open crib. Lusty cry. A:\nAppropriate. P:Comfort measures\n5. PARENTING O: No social contact this shift thus far.\n8. CV/RESP O: remains on 500cc N/C at 55-60% Fio2.\n BBS cl and equal with mild SC/IC retractions noted. Chest\nexcursion symmetrical. Upper airway congestion noted,\nimproving after sxn. Infant suctioned with cares for\ncopious thick mucousy secretions with plugs. Infant more\ncomfortable after suctioned. Recd Diuril as ordered.\nGeneralized edema noted. HRR with soft murmur. Pulses\npalpable and nonbounding. Occasional sats drift to hi\n80s,self resolved. A: Stable on N/C. Stable CV P: Titrate\nFio2 to maintain sats in 90s. CPT and suction q4. Monitor.\n. A:\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-13 00:00:00.000", "description": "Report", "row_id": 1788698, "text": "Neonatology\nDoing well. Remains in NCO2. Flow 500 cc and 50-70%. Generally comfortable WOB. Increased work with feeds.\nDiruil staretd yesterday.\n\nWt 2640 down 30. TF at 130 cc/k/d of 30 cal. Abdomen bneign. Mainly gavage, but starting to take feeds well.\n\nContinue to monitor resp status.\nWill recheck lytes over weekend.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-13 00:00:00.000", "description": "Report", "row_id": 1788699, "text": "Neonatology- Physical Exam\n\n remains in NC. Active, in an open crib,AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr 1-2/6 murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-13 00:00:00.000", "description": "Report", "row_id": 1788700, "text": "NPN 0700-1900\n\n\n#2 O: TF= 130cc/kg/d. Infant taking 57cc's of BM 30 with\npromod q 4h via po/pg feeds. Mom plans to BF at 1700 cares.\nAbdomen benign; voiding and tiny amount. No spits,\nminimal aspirates. Continues on diuril, iron, vit E and kcl.\nA: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in . Awake and with cares;\nsleeping well between. AFSF. Sucks on pacifier when offered.\nA: AGA. P: Cont to support development.\n\n#5 O: Mom called x1 for update. Plans to visit for 1700\ncares. Asking appropriate questions. A: Involved. P: Cont to\nsupport and update.\n\n#8 O: Remains in NC o2 500cc's of flow at 50-60% fio2. RR\n40's-80's with mild SC retractions. LS clear and =. Nasal\ncongestion noted; suctioned each nare for lg thick yellow\nsecretions. No spells. A: Stable in NC at present. P: Cont\nto monitor.\n\n#9 O: Soft murmur heard. BP 86/64 mean 71. HR 150's-160's.\nColoring and well perfused. Pulses are normal. A: CV\nstable thus far. P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788535, "text": "NPN 7a-7p\n\n\nFen\nInfant with TF 150 cc/k/d of BM/PE 24, gavage fed over 40\nmins. Abd soft with occasional transient loops. Stools with\nq diaper change. Fissures visible. A&D applied. Heme -\nstool. Spit x 1, sm amt. Asp max of 1.2 cc, non bilious,\npartially digested formula. AG stable. Active BS. Tolerating\nTF. No increase in calories. Monitor weight and exam.\nG/D\nIn off isolette, swaddled and with T-shirt. Sheepskin\nremoved because of warm temp this am. Stable temps\npresently. A/A with cares. Sleeps well when prone. FOS&F.\nH/U/S done this am was normal per fellow. MAEs. AGA. Monitor\nfor milestones and support G/D.\nParenting\nBoth in today to visit at the same time. They are\n\"together\" per Mom, but do not live together. They updated\neach other about visits and their daily activities. Mom held\nand participated in cares. She asked appropiate questions\nand was engaging and loving with infant. Father was busy\nwith older sibling at bedside. Invested and loving .\nSupport and educate.\nResp\nInfant having frequent and persistant drifts to the mid, low\n80s. Particulary after a feeding. Placed on 50cc NC @ 100% @\n14hrs. Sats improved to 94-96%. Will wean as possible. LSC.\nS/C I/C rtxs. Frequent sneezes. No drainage from nose or\neyes. No spells. On caffiene. Sm 02 requirment, new. Monitor\nand support resp status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788536, "text": "Fellow note: physical exam\nAlert, active. IN NC O2. RRR S1S2 nl No murmurs. Femorals palpable. Mild retractions. CTAB. - visible loop. Soft, NTND. BS present. Stool in diaper. AFOF Tone and power AGA MAEW CR < 2 secs.\n\nFor Babygram to assess aetiology of O2 requirement and evaluate for possible NEC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788537, "text": "Rehab/OT\n\nCare plan posted at the bedside. To meet with family in the next week. OT to follow. Please refer to care plan for details and care recommendations.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-07 00:00:00.000", "description": "Report", "row_id": 1788538, "text": "NPN 1900-0700\n\n\n2. F&N: TF remain at 150cc/k/d of BM24. Feeds gavaged\ninover 45 minutes. Abd full at 2100 with soft loops noted.\nBabygram done and WNL. A/G 23cm. No spits and minimal\naspirates. No loops noted at 0100. No spits. Voiding well\nand passing green stool with each diaper. Weight gain 10\ngrams.\n\n4. DEV: is active and alert during her cares. Temp\nstable swaddled in off isolette. She occasionally sucks on\nher pacifier.\n\n5. PAR: Mom called for update X1.\n\n8. RESP: Pt received in lwo flow nasal cannula, requiring\n50cc. FLow weaned down to 25cc this shift. Nares sxn X1\nfor mod white secretions. Lung sounds are clear. Mild\nretractions. No spells noted. Pt is on caffeine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-07 00:00:00.000", "description": "Report", "row_id": 1788539, "text": "Neonatology Attending\n\nDay 10\n\nPlaced on low flow nasal (25-50 cc/min) cannula yesterday for saturation drifts. No bradycardia on caffeine. CXR was reassuring. . No murmur. BP mean 51. Weight 1380 gms (+10). TF at 150 cc/kg/d. On BM 24. Stable abdominal girth. Minimal aspirates. On vitamin E and iron. Bilirubin 4.3/0.3. Swaddled in off incubator.\n\nMild respiratory insufficiency. Will continue to monitor closely, weaning oxygen as allowed. Advancing to 26 cal/oz feeds. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-06 00:00:00.000", "description": "Report", "row_id": 1788668, "text": "Neonatology Attending Note\nDay 40\nCGA 37 3\n\nHiFlow 500cc, 70-80%. RR30-60s. Occass RR80s. +Sc/ic rtxns. Occass QSR drifts. +Murmur. HR 150-170s. pale, but well perfused. BP 69/35, 46.\n\nWt 2365, up 15 gms. TF 130 BM30 w promod alt po/pg. well. Nl voiding. Tr stool. On Vit E and Fe. On KCl.\n\nIn open crib.\n\nA/P:\nContinues to make good progression, although slow and gradual. No changes to current plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-06 00:00:00.000", "description": "Report", "row_id": 1788669, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=130cc/kg/day of BM30w/PM. Alt PO/PG\nfeeding. Inf PO fed at 1300 taking only 35cc w/ some\ndifficulty coordinating suck,swallow, and breathing. \nfeeds well. No spits, asp thus far. Belly soft, no\nloops. Inf voiding, trace with each care. P cont\nto assess FEN needs,\n4. DEV O/A remains in an with stable temp.\nA/A w/cares. Waking for some cares this shift. P cont to\nassess dev needs.\n5. O/A Mom called for updates. P Mom plans to\nvisit tomorrow. Cont to support, and educate.\n8. Resp O/A Rec'd inf NC. Inf remains in NC 500cc\n65-75cc this shift. No spells thus far. P cont to assess\nresp needs.\n9. CV O/A Inf pale but well perfused. P cont to assess\ncv needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-07 00:00:00.000", "description": "Report", "row_id": 1788670, "text": "NPN 7p7a\n\n\nFEN\nWt 2.430 (+65). Restricted TF 130 cc/k/d alternating PO/PG,\nBM 30 PM. Bottled x 2 overnight, took full amt x 1, and took\n33 of 53 cc with the other. Had max asp of 5 cc, partially\ndigested and benign. Abd full, soft. Very gassy, trace\nstools. Appears to be trying to stool. No spits. Active BS.\nTolerating TF. Monitor weight and exam. Admin vit e, iron\nand KCL as ordered. Obtain lites on Monday am.\nG/D\nInfant in with stable temps. A/A with cares. Sucking on\nfingers and pacifier. MAEs. FS&F. AGA. Monitor milestones\nand support G/D.\nParenting\nNo contact from overnight.\nResp\nInfant in NC 500cc flow using 70-90% fio2 to maintain sats.\nRR 40-70s. S/C I/C rtxs. LSC. Upper airway congestion. Mild\nincrease in o2 needs compaired to day shift. Cont resp\nsupport.\nCV\nInfant with intermittent murmur and mild generalized edema.\nHR 150-160s. BP 73/50 (57). Pulses okay. Pale. Infant in\nNAD. Monitor and support CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-07 00:00:00.000", "description": "Report", "row_id": 1788671, "text": "Newborn Med Attending\n\nDOL#41. Cont in high flow O2 per NC. AF flat, clear BS, + murmur, abd soft, MAE. WT=2430 up 65 on 130 cc/kg/d Bm30 with PM, PO/PG.\nA/P: Growing infant with CLD. Cont to encourage PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-03 00:00:00.000", "description": "Report", "row_id": 1788784, "text": "PCA NOTE\n\n\nNUTR: O-Weight 3140, ^80gm. TF 130cc/k/d of BM 26 with enf\npowder. AD LIB. (67cc Q4H). PO. Waking Q2-5H. See flowsheet\nfor specifics. is voiding, trace stool. Active B.S.\nAbdomen is unremarkable. Small spit noted.\n A-Tolerating feeds.\n P-Continue with current regimen as ordered.\n\nDEV: O-Temp stable in . Waking for feeds. and\nactive with cares. Staying awake for longer periods of time.\nSleeping peacefully. MAE. Curious disposition. Enjoying the\nswing.\n A-AGA.\n P-Continue to monitor for developmental milestones.\n\n: Mom called, updated by nurse .\n\nRESP: O/A-In RA. Breathing 40-50's. Lungs are CL/=.No spells\nnoted. 2 choking episodes with feed (sats 81x2). QSR when\nbottle removed. No drifts.\n P-Continue to closely monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-03 00:00:00.000", "description": "Report", "row_id": 1788785, "text": "Neonatology Attending Note\nDay 67\n\nRA. RR40-60s. On diuril/kcl. 2 w/ feedings. Last brady . No murmur. HR 130-160s. Pale/.\n\nWt up 80 gms to 3140. TF 130 cc/k/day BM26. All po, though uncoordinated esp at end of feed. Nl voiding and .\n\nIn open crib.\n\nA/P:\ncont to monitor feeding coordination and encourage skills\nno change to nutritional plan\ngood overall growth, will decrease cals to 24\n" }, { "category": "Nursing/other", "chartdate": "2195-11-10 00:00:00.000", "description": "Report", "row_id": 1788685, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 56cc q4h pg. Infant bottling or breastfeeding q\nshift. Abdomen is soft, voiding having trace stools. No\nspits or aspirates. A: Tolerating feeds. P: Encourage po\nfeeds.\n\n#4 DEV S/O: Infant maintaining temps in . with\ncares, sleeping in between. Sucking on pacifier. A: AGA P:\nContinue to support dev.\n\n#5 Parenting S/O: Mom called this am for updates. States she\nwill be in to breastfeed at 5pm. A: Inolved, loving. P:\ncontinue to support.\n\n#8 RESP/CV S/O: Infant remain in NC, 500cc, FiO2 55-75%.\nLungs are clear with subcostal/ic retractions. RR 60-80's.\nNasally suctionedx1 with suction cath for mod yellow\nsecretions, for upper airway congestion. Frequent drifting\ninto upper 80% today. No spells. HR 160's. BP stable. Murmer\nheardx1 today. A: Stable in NC P: Continue to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-21 00:00:00.000", "description": "Report", "row_id": 1788730, "text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. Remains in nasal cannula O2 50-60% 500cc to keep O2 sats greater than 87. BS clear and equal with mild subcostal retractions, color pale . RRR, without murmur on auscultation (hx of soft murmur), pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-21 00:00:00.000", "description": "Report", "row_id": 1788731, "text": "Neonatology - NP Physical Exam\nAddendum: Remains on diuril and KCL. No obvious thrush noted in mouth\n" }, { "category": "Nursing/other", "chartdate": "2195-11-21 00:00:00.000", "description": "Report", "row_id": 1788732, "text": "Neonatology Attending Progress Note:\nDOL #59\ncontinues on NC 500cc 50%\nbreath sounds clear, mild ic/sc retx. mild upper airway congestion, no spells.\non diuril\nsoft murmur\nBP mean =47, HR=140-160\nwt=2819g (inc 5g), BM 30 with Promod po/pg TF=130cc/kg/d\nvoiding \nopen crib\nImp/Plan: x-31 week infant with late-onset lung disease\n--consider swallowing study\n--continue wean flow and oxygen as much as possible\n--consider Lasix when HCO3 decreases more\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-21 00:00:00.000", "description": "Report", "row_id": 1788733, "text": "0700- NPN\n\n\nRESP: Cont on NC 500cc 55-60%. RR 40's-50, O2 sats 89-96%.\nLS clear/=. Mild SC retractions. Mild upper airway\ncongestion noted, no suctioning done this shift. No A/B\nspells. Occasional drifts in O2 sats to 80%'s that are QSR.\nOn Diuril. P: Cont to monitor and wean O2 as tolerated.\n\nCV: Has soft murmur. HR 140's-160's. BP 69/33 mean=46.\nPeripheral pulses normal. Cap refill brisk. Pt is ,\nwell perfused. P: Cont to monitor.\n\nFEN: TF=130cc/kg/d of BM30 with PM PO/PG. Pt bottlefed x\n1, taking 40cc. Mom attempted to BF x 1, pt sleepy. No\nspits. Minimal aspirates. Abdomen benign. Voiding, no\nstool. On Ferinsol, Vit E, KCl. P: Cont to monitor and\nencourage PO feeding.\n\nDEV: Temps stable in , pt dressed/swaddled. MAE,\n/active with cares. Sleeps between cares, not waking\nindependently for feeds. Sucks pacifier and brings hands to\nface for comfort. Fontanels soft/flat. AGA. P: Cont to\nsupport growth and development.\n\nPARENTING: Mom in to visit this shift, updated by RN,\nasking appropriate questions. Mom held infant, participated\nin care. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-06 00:00:00.000", "description": "Report", "row_id": 1788799, "text": "0700- NPN\n\n\nFEN: TF=130cc/kg/d of BM24(with enfamil powder) po q4hr.\nInfant bottled 80 cc at 0900 and 1300 care. Infant bottled\n10cc and BF <5min at 1600 (see flowsheet). Abdomen soft,\nround, , +BS, no loops. No spits. Voiding, no stool.\n\nG&D: Temps stable, swaddled in . Active and with\ncares, sleeps between. Independently wakes for feeds. Brings\nhands to face. AGA.\n\nParenting: here at 1600, DC teaching reviewed with\n (see DC instruction sheet). Mom demonstrated\nmedication administration. Carseat instructions reviewed\nwith mom. asked appropriate questions. Questions\nanswered. instructed to call for any problems,\nconcerns, and/or questions.\n\nRESP: Infant in RA, O2 sats 95-100% RR=30-60's. Breath\nsounds clear and equal. Mild upper airway congestion noted.\nMild SC retractions noted. No bradys or .\n\nInfant dc'd to home with mom and .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-10 00:00:00.000", "description": "Report", "row_id": 1788552, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in nasal cannula requiring 75-150cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. No apnea or bradycardia\nobserved so far this shift.\nA: Continued O2 requirement.\nP: Support adequate ventilation.\n\nNUTRITION\nO: Caloric density increased to 28 cals/oz with the 1300\nfeed. Infant taking TF 150cc/kg/day of 28BM with PM by\ngavage every 4 hrs. Abd exam benign. Voiding and passing\nlarge yellow/green heme neg stool. Minimal asps and no spits\nnoted.\nA: No evidence of intolerance to feeds.\nP: Assess.\n\nDEVELOPMENT\nO: Temp stable in off isolette dressed in t-shirt, blanket\nand hat. Active and alert with cares. Sleeps between. Wakes\nfor feeds. Sucking on pacifier.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: No contact with so far this shift.\nA: Unable to assess.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788553, "text": "PCA NOTE\n\n\nNUTRITION: O/Weight 1515, ^25gm. TF 150cc/k/d of 28 cal BM.\n38cc Q4H. PG. See flowsheet for further examination. PT is\nvoiding and stooling. Hem neg. +. Girth is stable.\nAbdomen is unremarkable. Max aspirate at 1cc. No spits.\n A/Tolerating feeds.\n P/Continue with current regimen as ordered.\n\nDEV: O/Pt received in off iso. Temp is stable. Swaddled.\nSlowly waking for feeds. Alert and active with cares.\nSleeping peacefully. MAE. AFSF. Sweet disposition.\nA+D/Desitin applied to affected area. Repeat PKU to be sent\nthis A.M.\n A/AGA.\n P/Continue to monitor for developmental milestones.\n\n: No contact thus far this shift.\n\nRESP: O/Pt received in NC 100%, 125-150cc flow. Has not\ntolerated weaning this shift. Breathing 50-60's. Sats mid\n90's. Lungs are CL/=. On caffeine. No spells or desats\nnoted. Drifting when weaning attempted.\n A/In NC.\n P/Continue to closely monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788554, "text": "PCA NOTE\nASP. AT 0500 FEEDING BRIGHT GREEN. SPIT UP BRIGHT YELLOW. AFEBRILE. ABD SOFT. +BS THROUGHOUT. EXAMINED BY NNP. NO CHANGE IN PLAN. INFANT FED. ; AGREE WITH ABOVE NOTE WRITTEN BY PCA .\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788555, "text": "Neonatology Attending\nExam mild retractions, sl coarse bs, NCO2 in place, AF soft, flat, no murmur, mildly distended abd, but soft, no loops, normal bs, nontender, no hsm, active, normal tone for age, stool in diaper, no gross blood\n\nBabygram with hazy lungs bilaterally with ? something behind infant on R causing increased density, normal heart size, sl rotated, large stomach bubble with ngt in stomach, no pneumatosis or concerning loops, mild dilation\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-11 00:00:00.000", "description": "Report", "row_id": 1788556, "text": "Neonatology Attending\n\nDOL 14 CGA 33 4/7 weeks\n\nIn NCO2 since DOL 9. Requiring 100-125 cc to keep sat 88-94%. R 40s-60s. No A/B. On caffeine.\n\nBP 64/44 mean 50.\n\nOn 150 cc/kg/d BM 28 with promod pg. 1 cc green tinged aspirate with benign abd and heme neg stools. ngt found to be low and pulled back and retaped with improvement. Voiding. Stooling (heme neg). Wt 1515 grams (up 25).\n\nStable temp in off isolette.\n\n visiting and up to date.\n\nA: Stable. Requiring NCO2 ? development of CPIP vs need for stimulation for periodic breathing. On caffeine with spells controlled.\n\nP: Continue NCO2 as needed\n CXR\n Otherwise continue current regimen\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788647, "text": "npn 1900-0700\n\n\n#2 fen\ntf 130cc/kg of bm30 with promod gavaged/po q4hours. wt.\n2.190kg (-105gms). abd benign. voiding and brown\nguiac neg stools. desitin to bottom. max aspirate 9cc\npartially digested milk, no spits. aspirate of 4cc at\nbeginning of night with blood present tossed. \nbuck aware and into see pt. lytes 136, 4.2, 89, 12.\n#4 g&d\npt in open crib with stable temps. and active with\ncares. maew. fontanelles soft and flat. sucking on binki and\nfingers.\n#5 parenting\nmom called in evening for update. asking appropriate\nquestions. involved and loving parent\n#8 resp\npt continues on nc fio2 100% with flow 75-125cc. lsc=. sc\nretractions. rr 50-80's. occational drift to mid 80's. no\nbrady's thus far this shift.\n#9 cv\npt with soft murmur present. pulses normal. hr 140-160's.\n and well perfused.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-02 00:00:00.000", "description": "Report", "row_id": 1788648, "text": "Neonatology Attending Note\nDay 36\nCGA 36 5\n\nNC 100%, 75-125cc. Cl and =. RR50-80s. +SC rtxns. +Sat drifts-qsr. HR 140-160s. +Soft murmur.\n\nWt 2190, down 105. TF 130 cc/k/day BM30 w promod pg>po. well. Nl voiding and .\n\nLytes:\n136/4.2/89/39\n\nEyes - immature zone 3\nIn open crib.\n\nA/P:\n with continued pulmonary concerns with unclear etiology to delayed presentation of aveolar disease. In addition has a persistent metabolic alkalosis which may be compensation for lung disease.\n - resp: CXR c/w alveolar dz, appears like HMD but again delayed in presentation. need to consider less common etiologies; however, will contnue to monitor for now and track overall progress prior to consulting pulmonology. Change to hi-flow system to see if this increases reserve and therfore endurance and tolerance with daily activities (feeding, handling).\n - CV: cardiac disease and contribution to pulmonary process has been ruled out\n - FEN: no changes to current nutritional plan. Will follow electrolytes. Will try to correct with KCL and possibly diamox\n - Renal: Initial set of urine electrolytes not c/w Barter's. Will check another set in a couple of days (remote from lasix dose Sunday). Add BUN/Cr to today's electrolytes and check renal ultrasound.\n - ID: Has undergone multiple sepsis evaluations - all negative to date.\n\nI had a family meeting with both yesterday to explain current medical plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-12 00:00:00.000", "description": "Report", "row_id": 1788691, "text": "NPN 1900-0730\n\n\n2. WT. 2.670GMS WT. UP 40 GMS FROM YESTERDAY. TF CONT. AT\n130CC/K/D OF BM30 WITH PROMOD. NO SPITS OR ASP. NOTED. ABD\nSOFT, NO LOOPS, +BS THROUGHOUT. SMALL LIQUID STOOL NOTED,\nBLACK, GUIAC-. VOIDING WELL. PLAN; CONT. TO MONITOR\nTOLERANCE TO FEEDINGS.\n\n4. REMAINS IN WITH TEMPS STABLE. A/A WAKING FOR CARES.\nRESP. STATUS IMPROVED WHEN INFANT SLEEPING ON STOMACHE.\nCONT. TO BE MAINLY A PG FEEDER. ATTEMPTING PO FEEDING 1X Q\nSHIFT IF APPEARS ABLE TO TOLERATE VIA RESP/STATUS. L EYE\nREMAINS SWOLLEN. TEAM AWARE. NO DRAINAGE AT PRESENT. PLAN;\nCONT. TO SUPPORT G/D MONITOR L EYE FOR WORSENING SWELLING.\n\n9. HR MAINLY 160'S. MURMER NOT HEARD THIS SHIFT. APPEARS\n AND WELL PERFUSED. PLAN; CONT. TO MONITOR STATUS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788750, "text": "Neonatology\nDOwn to RA this am. Comfortable apeparing. IN RA flow this am. Will continue to attempt to wean flow.\nSpoke to mother this am.Remaisn on diuril. Lytes to be checked in am.\n\nWt 2960 up 75. Tolerating feeds well at 130 cc/k/d of 30 cal. Will wean cals to 28 cal. Awaiting ability to maintain adequate intake.\n\nSpoke to mother this am. Her older child is in with case of Fifth disease.\n\nWill discuss Synagis with family.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788751, "text": "Clinical Nutrition\nO:\n~40 wk CGA BG on DOL 59.\nWT: 2960 g (+75)(~25th to 50th %ile); birth wt: 1370 g. Average wt gain over past wk ~35 g/d.\nHC: 34 cm (~50th to 75th %ile); last: 33 cm\nLN: 46.5 cm (~10th to 25th %ile); last: 46.5 cm\nMeds include Fe, Vit E, diuril, KCl, and prune juice tsp .\n not needed\nNutrition: 130 cc/kg/d BM 28 w/ promod, po/pg. Infant taking full volume of feeds when she po's. Feeds just decreased today due to good wt gain. Projected intake for next 24 hrs ~121 kcal/kg/d and ~3.6 g pro/kg/d.\nGI: Abdomen benign. Max aspirate 8 cc, refed. Infant had BM guiac - after glycerine supp. Just started on prune juice yesterday.\n\nA/Goals:\nTolerating feeds without GI problems except aspirate as noted above, likely due to need to stool. Infant requiring glycerine for BM's; started on prune juice so will monitor for effectiveness. Learning po feeding skills. not needed. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. Kcals were decreased as wt gain is at upper end of range (20 to 35 g/d) and growth curve looks good. LN shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788752, "text": "NPN Days\n\n9 Alt in CV\n\n#2 FEN: TF =130cc/kg/day of BM 30w/ promod 60cc Q 4 PO/PG.\nAbd benign. AG 29.5. asp. No spits. Voiding. Trace\ngreen stools, heme neg. P: Cont to encourage po's & plan\nto decrease to BM 28cal w/ promod.\n#4 G&D: Temps stable in open crib. & active.\nSucking on pacifier. P: cont to monitor.\n#5 Parenting: Mom called today. Asking approp questions.\nUpdates given. P: cont to support & educate.\n#8 Resp: Pt. received & cont on NC. Weaned O2 to 21% w/\n200cc flow. No spells. Cont w/ upper airway congestion. P:\n Cont to monitor resp status.\nsee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 9 Alt in CV; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-26 00:00:00.000", "description": "Report", "row_id": 1788753, "text": "NPN 1900-0700\n\n\nFEN: PO all feeds so far this shift, taking full volume. No\nspits or aspirates. Abdomen benign, girths stable. Voiding,\nno stool this shift.\n\nG/D: Temps stable swaddled in . Wakes for feeds, A&A\nw/cares. AFSF, likes pacificer.\n\n: Mom called X1 for update. Verbalized happiness\nregarding progress w/feeding.\n\nRESP: In RA NC, mild SCR. Congested upper airways, sats\nstable, did not suction.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-26 00:00:00.000", "description": "Report", "row_id": 1788754, "text": "Addendum to NPN\n\n\nPt was suctioned @ 0700 for moderate amount of cloudy\nsecretions from nares and mouth. Sats improved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-16 00:00:00.000", "description": "Report", "row_id": 1788580, "text": "Neonatology Attending\n\nDay 19\n\nRemains on nasal cannula at 100 cc/min flow. Occasional mild drifts. RR 50-70s. On caffeine. HR 130-160s. Four ext bps normal. Hyperoxia passed. Weight 1685 gms (+30). TF at 150 cc/kg/d. All pg feeds of BM28 with Promod. Blood glucose 122. Stable temperature in open crib.\n\nRespiratory insufficiency continues. Cardiac evaluation unrevealing. Will continue to monitor closely. Weaning oxygen as allowed. Gaining weight well.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-16 00:00:00.000", "description": "Report", "row_id": 1788581, "text": "NPN 1520\n\n\n#2 F/N: Baby Girl remains on 150cc/kg/d BM 28 +\nPromod, 41cc all pg fed. Infant offered po X1, did not suck.\nTolerating pg feedings well. Abd full and soft, voiding and\nstooling.\nA: feeds, no interest in bottling.\nP: Cont to assess readiness to bottle feed. Assess for\nchange in feeding tolerance.\n#4 Dev.: Infant awake and alert for cares. Remains in an\nopen crib, swaddled w/i boundaries.\nA: AGA, 34 wks corrected.\nP: Cont dev. supports.\n#5 : No contact thus far on shift.\n#8 Resp: Received infant on 100cc flow oxygen, now at 150cc\nflow, 100%. Infant w/ O2sats 85-86% necessitates increase in\nflow. RR today 70-90's, mild IC/SCR. Color ruddy .\nA: Somwhat tachypneic today.\nP: cont to assess increased need for oxygen, monitor resp.\nrates and work of breathing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-17 00:00:00.000", "description": "Report", "row_id": 1788582, "text": "Neonatology Attending\n\nDay 20\n\nRemains on nasal cannula- 75-100 cc/min. Occasional desaturations on caffeine. RR 60-80s. Mild retractions. PPS Murmur continues. HR 130-160s. BP mean 45. Weight 1710 gms (+35). TF at 150 cc/kg/d- BM 28 with Promod. All gavage. Stable temperature in open crib.\n\nRespiratory insufficiency. Monitoring. Gaining weight well. Still not interested in feeding. Will encourage.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-17 00:00:00.000", "description": "Report", "row_id": 1788583, "text": "Nursing note\n\n\n#2O: On 150cc/kg/d BM28 with promod, q 4 hr. feeds. Belly\nsoft voiding and stooling. Will put to breast for the 1st\ntime later.\n#4O: In open crib with stable temp, acive with cares, loves\npacifier.\n#5O: Mom and brother into visit and was updated at the\nbedide.\n#8O: In nasal cannula 100% 50 -125 cc at rest, increased\nwith cares, on Caffeine q d. Br. sounds cleai with\nretractions.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-18 00:00:00.000", "description": "Report", "row_id": 1788584, "text": "NPN\n\n\n#2 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of BM 28\ncals w/Promod w/o spits. Minimal asps.Feeds given on a pump\nover 40 mins q 4 hrs. voiding+ stooling in adeq amts. Wt up\n50gms.TF= 150cc/kg/day.\n#5 - No contact yet tonight.\n#8 Resp- Remains in NC 100% 25-75cc.RR= 50-90.BS clear. Mild\nretractions. Remains on caffeine. No A's or B's yet tonight.\nSee flowsheet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-18 00:00:00.000", "description": "Report", "row_id": 1788585, "text": "Neonatology Attending Progress Note:\n\nDOL #21\nx-31 4/7 weeks\non NC 25-75cc\non caffeine, no spells, RR=40-100, HR=150-180's\nwt=1760 (inc 50), BM 28 with promod\nvoiding, stooling\n\nPE: well appearing, AFOF, normal S1S2, soft I/VI systolic murmur, breath sounds clear, mild tachypnea. abdomen soft, nontender, nondistended, ext warm, well perfused.tone aga.\n\nImp/Plan: x-31 week ifant with persistent residual lung disease, murmur probably due to PPS now F and G.\n--monitor murmur\n--wean oxygen as tolerated\n--encourage po feeds.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-17 00:00:00.000", "description": "Report", "row_id": 1788715, "text": "0700- NPN\n\n\nRESP: Remains on NC 500cc 50-60%. RR 37-60, O2 sats\n89-97%. LS clear/=. Mild SC retractions. No A/B spells.\nOccasional drifts in O2 sats to 70-80%'s, some QSR and some\nrequiring increased O2. P: Cont to monitor and wean O2 as\ntolerated.\n\nCV: Has soft murmur. HR 150's-170's. BP 64/49 mean=54.\nPeripheral pulses normal, cap refill brisk. Pt , well\nperfused. P: Cont to monitor.\n\nFEN: TF=130cc/kg/d of BM30 with PM (59cc Q4hr) PO/PG. Pt\nbottlefed x1, taking 42cc PO. No spits. Max aspirate of\n3.2cc. Abdomen benign. Pt is voiding, trace stools x 2.\nPt on Ferinsol, Vit E, KCl. P: Cont to monitor and\nencourage PO feeding.\n\nDEV: Temps stable in . MAE, /active with cares.\nSleeps between cares, waking independently for feeds. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. AGA. Pt has oral thrush, Nystatin given as\nordered. P: Cont to support growth and development.\n\nPARENTING: Mom in to visit, updated at bedside by RN,\nasking appropriate questions. P: Cont to support/educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-18 00:00:00.000", "description": "Report", "row_id": 1788716, "text": "Nursing Progress Note\n\n\n2.O: Weight 2715gms up 50gms. On BM 30cal with promod\n59cc's q4h= 130cc/kg/d. Gavaged x1 and tolerated well. To be\nbottled this AM. Abdomen benign, voiding qs. Kcl supplements\nto be given this AM.\n A: Continues to gain weight.\n P: Offer 2 bottles per shift. Monitor weight gain and s&s\nof edema.\n4.O: Starting to wake up for feeds. Active and for\ncares. Swaddled and nested in an open crib. Temp stable.\nSucking on pacifier intermittently.\n A: Gestationally appropriate.\n P: Continue with interventions.\n5.O: No contact this shift.\n8.O: Remains in a nasal cannula 500cc's 50-60% most of\nshift. No or spells noted. Breath sounds clear and\nequal, lips and nailbeds . Diuril given as ordered.\n A: RDS.\n P: Continue with present plan. Wean O2 as tolerated.\nDocument spells.\n9.O: Resting HR 130's-160's. Soft murmur heard. Good color\nand perfusion.\n A: Unfected by murmur. BP stable.\n P: Continue to monitor.\n10.O: Nistatin given as ordered.\n A: Thrush.\n P: Continue with Treatment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-18 00:00:00.000", "description": "Report", "row_id": 1788717, "text": "Neonatology\nRemains in NCO2 50-60% 500 cc. Back up in O2 from yestredays level. COntinues on diruil. WIll plan to recheck lytes in am.\n\nWt 2715 up 50. TF at 130 cc/k/d of 30 cal. Abdomen benign. STill requiring gavage. Will recheck lytes in am.\n\nWIll continue to reassess O2 requirement. If not consistent dcereases with diuril rx will consider Ba Swallow next week to assess possibility of reflux with aspiration.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-18 00:00:00.000", "description": "Report", "row_id": 1788718, "text": "Neonatology- Physical Exam\n\n remains in NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-22 00:00:00.000", "description": "Report", "row_id": 1788734, "text": "NPN\n\n\n#2\nInfnt remains on TF=130cc/k of BM30 with promad q4 hours.\nInfant has bottled x2 thus far tonight and taken 51cc/25cc;\nremainder via gavage. Abd is soft and round; voiding well;\nno stool. Wt is up 60gms-2870.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nInfant is with cares; not waking for feeds; but\nappears eager to eat when she is awake. Temp has been\nstable.\n\n#5\nNo contact tonight from .\n\n#8/#9\nInfant remains in N/C 500cc flow; 50-60% maintaining sats\nlow 90s. Occasional drifts in sats. BS clear= with mild\nretractions. Mild upper airway congestion noted. Continues\non Diurel. Color is pale ; murmer audible. No spells\nnoted.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-05 00:00:00.000", "description": "Report", "row_id": 1788795, "text": "0700- NPN\n\n\nFEN: TF= 130cc/kg/d of BM24 po q 4hr. Infant bottled 60cc at\na.m. feeding, BF >10 + bottled 10cc at afternoon\nfeeding, and bottled 100cc at evening feeding. Abdomen ,\nsoft, +BS, no loops. No spits. Voiding and , guiac\nneg. Continues on prune juice .\n\nG&D: Temps stable, swaddled in . Active and .\nIndependently wakes for feeds. Reaches to face with hands.\nUses pacifier for comfort. AGA.\n\nParenting: Mom in today for afternoon care. BF X1 >10 .\nMom independent, involved, and loving. Asking appropriate\nquestions. Teaching re medication administration reviewed\nwith mom. continue to support mother.\n\nRESP: Remains in RA, O2 sat 93-99%, RR=30-60's. Breath\nsounds clear and equal. No increased work of breathing\nnoted. No , no bradys. Continues on Diuril/KCL. Day 4\nout of a 5 day brady countdown.\n\nWill cont to monitor infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-06 00:00:00.000", "description": "Report", "row_id": 1788796, "text": "NPN\n\n\n2.FEN: Infant remains on TF 130cc/kg/day of BM 24cal/oz.\nWt today 3235g (increased 40g). She is tolerating feeds\nwell with no spits. Infant took 80cc and 90cc po for the\nfirst two feeds. Abdomen is soft and full with active bowel\nsounds. She is voiding, one trace yellow stool thus far\nthis shift. Continue to monitor FEN status and encourage po\nfeeding.\n\n4.DEV: Infant is swaddled in an open crib with stable\ntemps. She is and active with cares, irritable at\ntimes. She is rooting vigorously and sucks on pacifier for\ncomfort. Continue to support growth and development.\n\n5.Parenting: Mother called this evening to check on\ninfant's status for discharge tomorrow. Infant is day \nof brady countdown. Mom planning on coming in for discharge\nteaching tomorrow. Continue to support and keep\ninformed.\n\n8.Resp: Infant remains in room air with 02 sats 92-99%.\nLung sounds are clear and equal, no retractions. She is\nbreathing comfortably with RR 40s-60s. Continue to monitor\nrespiratory status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-06 00:00:00.000", "description": "Report", "row_id": 1788797, "text": "Neonatology Attending Note\nDay 70\n\nRA. RR40-60s. On diuril/kcl. No murmur. HR 130-160s. Last BP 78/45, 59.\n\nWt 3235, up 40 gms. TF 130 cc/k/day BM24 w E powder. TFI: 114 cc/k/day +BF. Nl voiding and .\n\nIn open air crib.\n\nA/P:\ndemonstrating good CVR maturity, now even with feedings with no new events\nready for discharge to home today\nplease see dictated summary for further details\nf/u with pedi, pulmonary\nwill have VNA services\n" }, { "category": "Nursing/other", "chartdate": "2195-12-06 00:00:00.000", "description": "Report", "row_id": 1788798, "text": "Neonatology Attending Note\nd/c t>30'.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-21 00:00:00.000", "description": "Report", "row_id": 1788598, "text": "NPN 7a-7p\n\n\n#2: TF: 150cc/k/d. Conts on BM28withPromod, 'ing 47cc\nq4hrs gavaged over 1hr. No spits noted. benign asps.\nAbd soft, +, no loops. Voiding qs. . A:\n'ing feeds well P:Cont with current feeding plan.\nMonitor to feeds. Follow wt and exam. Nut labs .\n\n#4: Temps stable while swaddled in an open crib. Infant is\nwaking around care times. MAE. Fonts soft/flat. Sleeps\nwell in btw cares. Eye exam done- see note for details. F/U\nin 2-3wks. A:AGA P:Cont to support dev needs. 1mo HUS\nnext week.\n\n#5: Mom in this afternoon. Aware of eye exam results.\nIndep with care. Attempted to breastfeed infant, but infant\nnot interested. Update given. A: Involved, loving parent\nP:Cont to support and educate.\n\n#8: remains in NC 100%, 50-100cc flow at rest. With\ncares, handling, and supine position infant instantly desats\nand requires ^ to 200cc flow. RR 60-80's with occ ^'ed\ntachypnea 90-100's. Team aware. Mild IC/SC retractions\nnoted. No ^'ed WOB. BBS cl/=. No apnea/brady spells\nnoted. A: conts with O2 req P:Cont to monitor and provide\nsupport as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788599, "text": "Nursing Note\n\n\n#2O: Fluids at 150cc/kg BM28 with promod, q 4 hr. feeds.\nBelly soft voids qs, no stool. . asp. and 1 sm. spit.\nNutrition labs done, see flow sheet, d-s 57.\n#4O: Alert with cares, slightly irritable, sucks on\npacifier, temp stable in crib.\n#5O: No contact.\n#8O: Received infant with nasal cannula in place 100% 75cc.\n Increased O2 req. with desats accompanied by increase work\nof breathing. notified, CXR done which\nshowed fluid and a dose of Lasix was given. Infant briefly\nin 250cc 100% but has weaned to 150cc. Br. sounds are clear\nwith mild - mod. retractions and RR 40'3 - 100's.\nA: Increased O2 req. tonight P: ? decrease cc/kg, ? start\ndiuretics, monitors lytes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788600, "text": "Neonatology Attending Note\nExam:\n\nResting comfortably in no acute resp distress. However, will desat easily during exam, requiring inc O2. AFSF. +NC. +NG. Lungs CTA, +transmitted UA sounds. CV RRR, no murmur appreciated, 2+FP. Abd soft, +BS. Ext and well perfused.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-22 00:00:00.000", "description": "Report", "row_id": 1788601, "text": "Neonatology Attending Note\nDay 25\n\nCGA 35 1\n\nInc resp distress. CXR with suggestion of pulm edema, given 1 dose of lasix. Remains in NC. O2 need remains labile. Currently 100-150 cc. RR40-90s. BS clear. +SC rtxns.\n\nHR 150-170s. BP 68/36, 44. No murmur heard this am.\n\nWt , up 40g. TF 150 cc/k/day BM28 with promod. d/s 57. On vit E and Fe.\n\nIn open crib.\n\nA/P:\n - respiratory insufficiency - ? CPIP. Yet will also perform another cardiac evaluation, check ABG, and do another sepsis eval.\n - continues to tolerate enteral feedings, will continue w/ current plan\n" }, { "category": "Nursing/other", "chartdate": "2195-11-12 00:00:00.000", "description": "Report", "row_id": 1788692, "text": "NEONATOLOGY\nRemains in NCO@ at 500 cc 50-75%. WOB generally unchanged from levels of past few days. Murmur as before. Lytes stable. Will discuss beginning diuretic rx with family. Plan to begin diuril rx and monitor response.\n\nWT 2670 up 40 (up 175 in past 3 days) Tolerating feeds at 130 cc/k/d of 30 cal. ABdomen benign. Still req sig gavage.\n\nHct 30.9 retic pensding.\n\nTemp stable in open crib.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-12 00:00:00.000", "description": "Report", "row_id": 1788693, "text": "PCA 0700-1900\n\n\n#2 infant's current weight 2670g up 40g. infant remains on\nstrict TF of 130cc/kg=58cc q4h gavaged over 50 minutes. abd\nsoft, no loops, minimal asp., no spits, bs+, voiding qs, no\nstool thus far. P:cont. to support nutritional needs.\n\n#4 infant remains in . temp. stable. a/a with cares and\nsettles well in between. P:cont. to support dev. needs.\n\n#5 no known contact thus far.\n\n#8 infant remains on NC FIO2 50-70% 500cc flow, SATing\n85-99%, mild sc retractions, RR40-60, lung sound cl=. no\nspells thus far. P:cont. to monitor.\n\n#9 HR 150-170, infant has soft murmur, and well\nprofused. P:cont. to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-12 00:00:00.000", "description": "Report", "row_id": 1788694, "text": "Nursing Addendum Note\n\n\nI have read the above note written by PCA and\nagree with the information as stated. Patient was started\non Diurl this afternoon.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-12 00:00:00.000", "description": "Report", "row_id": 1788695, "text": "NPN 1500-2300\n\n\n#2: O: TF minimum 130cc/kg/d. of breastmilk 30 with promod,\n58cc q4hours gavaged over 50 minutes. Bottled once per\nshift. Abdomen soft, voiding, no stools this shift. No\nspells, no spits. A: Infant tolerating feeds. P: Continue to\nsupport PO feeding.\n\n#4: O: Temperature stable in , awake and , wakes for\nfeeds. Brings hands to face for comfort, sucks pacifier\nwhen offered. Remains swaddled in crib. A: AGA. P: Continue\nto support growth and development.\n\n#5: O: Mom in this evening. with cares and\nputting baby to breast. A: Loving parent. P: Continue to\nsupport , epecially mom with breastfeeding.\n\n#8: O: Infant remains in 500cc of nasal cannula o2 at 70%.\nSaturations 89-95%, respiratory rate 30's-60's. Lung sounds\nclear and equal. A: Infant stable in nasal cannula O2. P:\nContinue to monitor infant's respiratory status.\n\n#9: O: Heart rate 150's-170's, soft murmur heard. Infant is\n and well profused. Capillary refill brisk and pulses\nnormal. A: Infant stable P: Continue to monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788501, "text": "Neonatology\nDoing well. RA. Few spells. Comfortable appearing. No evidence of PDA.\n\nWt 1370 down 25. TF at 100 cc/k/d. Feeds at 50 cc/k/d. Abdomen benign.\nLytes this am notable for K 9.3 on grossly hemolyzed specimen.\nGood UO. EKG normal on monitor. TF to be increased to 120 cc/k/d. PN to continue. PN content verified on bag.\n\nType and coombs to be repeated.\n\nCliniclaly stable off abx.\n\nPhototherapy continues. Bili in 7 range this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 1788624, "text": "NPN Nights\n\n\n2. O: Wt 2090gms, up 15. TF 130cc/kg of BM28+PM po/pngt. Pt\ntook whole bottle at 0100 with good coordination and within\n10 mins. asp. No spits. Voiding. Trace stool. +bs. A:\n feeds. P: Cont to monitor wt, abd, and po intake.\n\n4. O: Temp stable swaddled in open crib. and active\nwith cares. Waking for feeds. A/P: Cont to cluster cares.\nCont to monitor temp.\n\n5. No contact from family thus far this shift.\n\n8. O: Received pt in NC100% 100-175cc flow. RR 40-70's. Mild\nsubcostal retractions. No spells. Tb sxn'd X1 for sm thick\nwhite. A/P: Cont to monitor resp status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 1788625, "text": "Neonatology Attending Note\nDay 31\n\nCGA 36 weeks\n\nNC 100%, 100-175cc. RR40-70s. Cl and + BS. No A&Bs. +Soft, int murmur. HR 150-170s. . Good pulses. BP 77/39, 51.\n\nWt 2090, up 15. TF 130 cc/k/day BM28 w promod. PO/PG. well. Nl voiding and .\n138/6.4/98/33\n\nOn Fe and Fe.\n\nIn open crib.\nDay 30 HUS today.\nEyes , immature f/u\n\nA/P:\n - O2 support as needed\n - ECHO does show small PDA, will discuss with Cardiology re: significance to lund dz\n - Marginal, slow growth. Now that she is restricted will increase cals to 30\n - f/u HUS results\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 1788626, "text": "Neonatology- Progress Note\n\nPE: remains in her open crib, in nasal cannula O2, bbs cl=, rrr soft systolyc murmur, abd soft, nontender, V&S, gavage tube in place, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2195-10-28 00:00:00.000", "description": "Report", "row_id": 1788627, "text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 31.\nWT: 2090 g (+15)(~10th to 25th %ile); birth wt: 1370 g. Average wt gain over past wk ~15 g/kg/d.\nHC: 30.5 cm (~10th to 25th %ile); last: 29.5 cm\nLN: 42.5 cm (~10th to 25th %ile); last: 40.5 cm\nMeds include Vit E and Fe\n not due\nNutrition: 130 cc/kg/d BM 30 w/ promod, po/pg. Infant takes ~ to full volume feeds po ~1 to 2 x per day. Feeds were just fluid restricted yesterday, so decision made today to increase kcals to maintain growth. Projected intake for next 24 hrs ~130 kcal/kg/d and ~3.6 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Feeds were just increased today due to fluid restriction started yesterday. Growth is meeting recs for wt gain and HC gain. LN gain is exceeding recommended ~1 cm/wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-01 00:00:00.000", "description": "Report", "row_id": 1788775, "text": "PCA Progress Note, 7p-7a\n\n\nFEN:\n TF:Min130cc/kg/D of BM26 w/Enfamil. Infant is all Po's,\ntaking full volumes Q4hrs and tolerating feeds well w/ no\nspits. Abd is benign w/active BS. Voiding and .\nRemains on prune juice.Please refer to Pt's chart for\nadditional FEN data. Continue to encourage and support PO\nfeeds.\n\nDEV:\n Infant's temp remains stable while swaddled in . Infant\nis and active w/ cares, wakes for feeds and sleeps\nwell in between cares. Sucks on pacifier for comfort.\nContinue to encourage and support developmental milestones.\n\nPAR:\n No contact by this PCA so far this shift. Mom called for\nupdates x2, no visits this shift. Continue to update and\nsupport.\n\nRESP:\n Infant remains in RA. O2 sats are stable. LS: cl/=. Mild sc\nretrax. No significant or spells so far this shift.\nPlease refer to PT's chart for additional RESP data.\nContinue to monitor and support RESP status and plan of\ncare.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-01 00:00:00.000", "description": "Report", "row_id": 1788776, "text": "Neonatology\nDOing well. Remains in RA. Comfortable apeparing on exam. No spells.\n\nWT 3115 up 40. Tolerating feeds at 130 cc/k/d . Taking all po. Good weight gain on 26 cal yesterday. WIll contineu currenbt.\nSynagis for today.\n\nPotential for dc in am if remains in RA.\n\nAwake . Neuro non-focal and age appropriate. Moving all 4 ext.\n\nSpoke with mother via phone yesterday\n" }, { "category": "Nursing/other", "chartdate": "2195-12-01 00:00:00.000", "description": "Report", "row_id": 1788777, "text": "NPN days\n\n\n#2FEN: TF 130cc/kg/day of BM 26w/ enfamil Q 4hrs. All po\nfeeding, taking 60-70cc's Q4hrs. Had spell X1 today w/\nlarge spit. MD aware. Abd soft & round. Voiding &\n. P: cont to monitor.\n#4G&D: Temps stable in open crib. Waking for cares.\nSucking on pacifier. AGA. Received synergis today. P:\ncont to monitor. Needs car seat test.\n#5Parenting: Mom called today. Updates given. Mom will be\nin for 5pm cares. Asking approp questions. Left message w/\nmom to bring in corn oil. P: cont to support & update.\nCont. discharge teaching.\n#8Resp: Pt remains on RA. RR 40-70's w/ mild subcostal\nretractions. Sats > 90%. Lungs clear & =. Spell X 1 w/\nspit. Decision made by MD to monitor for 24hrs before d/c.\nP: continue to monitor.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-12-01 00:00:00.000", "description": "Report", "row_id": 1788778, "text": "Nursing Note 1830\n here at 1730 to take infant CPR class. Both watched the video and participated in practicing compressions, breaths and choking maneuvers. Written handout given.\n" }, { "category": "Nursing/other", "chartdate": "2195-12-02 00:00:00.000", "description": "Report", "row_id": 1788779, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF 130cc/k/d. Infant to get bm 26 with Enfamil\nPowder, 67cc q4h po. Infant bottled 120cc, and 73cc so far\nthis shift. Abdomen is benign, voiding and . No\nspits. A: Tolerating feeds. P: Encourage po feeds.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive with cares, waking for feeds. Loves stroller. Infant\nfailed car seat test tonight. O2 sat throughout test 80-88%.\nNP. Synagis given. A: AGA P: Continue to support dev.\n\n#5 Parenting S/O: Mom called for updates this evening.\nExcited about infants progress. Asking about s weight\ngain and amount of bottling. A: Involved, loving. P:\nContinue to support and update.\n\n#8 RESP S/O: Infant in RA. O2 sats >94% with frequent drifts\ninto the mid 80's. Lungs are clear, subcostal retractions.\nRR 40-60's. Getting Diuril. Failed carseat test due to\nprolonged desaturations. A: Stable P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-01 00:00:00.000", "description": "Report", "row_id": 1788642, "text": "NPN NOCS\n\n\n2. O: Wt 2285gms, up 40. TF at 130cc/kg of BM30 with PM. Alt\npo/pg. Feeding gavged over 50min. Abdomen benign. Small\nspit. No residual. Voiding and . A: Working on po\nfeeds. P: Continue with plan and monitor.\n\n4. O: and active with cares. Temp stable in open crib.\nA: AGA. P: Continue to support dev needs.\n\n5. No contact from thus far this shift.\n\n8. O: Remains in NCO2 100% at 100-150cc. LS clear. Baseline\nSC retractions. RR 40-70's. No spells. A: Stable on O2. P:\nContinue to monitor, wean O2 as needed.\n\n9. Continues with soft murmur. VSS. BP 58/32 41. .\nContinue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-01 00:00:00.000", "description": "Report", "row_id": 1788643, "text": "NPN NOCS\nAddendum: Infant offered bottle with last care. Noted to have increased WOB and increased O2 requirement. Remainder gavaged. need to offer po only 1x/shift until better reserve.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-01 00:00:00.000", "description": "Report", "row_id": 1788644, "text": "Neonatology Attending Note\nDay 35\nCGA 36 4\n\nIn low flow O2, 100-150cc. RR40-70s. No A&Bs. No overnight. +Soft murmur. BP 58/42, 41. HR 150-170s.\n\nWt 2295, up 40 gms. TF 130 cc/k/day BM30 with promod po/pg. Nl voiding and .\n\nIn open crib.\n\nA/P:\n - Still w/ moderate O2 need, tires with po feedings and on exam some areas of edema (periorbital edema). Will try a trial of daily lasix x 3 days to see if she responds to diuretics.\n - No changes to nutritional plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-01 00:00:00.000", "description": "Report", "row_id": 1788645, "text": " On-Call\nPhysical Exam\nGeneral: sleeping infant in open crib, nasal cannula O2\nSkin: warm and dry color ; periorbital and tibial edema\nHEENT: anterior fontanel open, flat; sutures opposed; symmetric facial features\nChest: breath sounds equal, fine crackles\nCV: RRR without murmur; normal S1 S2; pulses +2/=\nABD: soft; no masses umbilicus healed\nGU normal female\nExt: moving all\nNeuro: appropriate tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2195-11-01 00:00:00.000", "description": "Report", "row_id": 1788646, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=130cc/kg/day of BM30 w/PM. Inf PG fed thus\nfar. well. No spits, asp thus far. Belly soft, no\nloops. INf voiding, trace stool. P Mom plans to BF baby at\nnext care time.\n4. DEV O/A remains in an w/stable temp. A/A\nw/cares. Sleeping well between cares. P cont to assess dev\nneeds.\n5. O/A Mom called for updates. P Plan to visit\nat 1700 cares.\n8. Resp O/A Rec'd inf in NC. Inf remains in NC 100%\n50-150cc. Occ'l to 70's. Day 1 of 3 of Lasix\nstarted as ordered. P cont to assess resp needs.\n9. CV O/A Soft murmur noted. and well perfused. P\ncont to assess CV needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-11 00:00:00.000", "description": "Report", "row_id": 1788686, "text": "NPN\n\n\n#2 TF 130cc/k/d of BM30 with promod=57cc Q4hrs on pump over\n50 . Infant bottled 53cc x1. Abd benign. No spits.\nAsp .8-1.4cc. Voiding and . Wt 2630(+65).\n\n#4 Infant nested in open crib with stable temp. Infant\nsettles best on abd. Infant sucks on pacifier.\n\n#5 No contact from .\n\n#8 Infant remains in NC 500cc/55-70%. Changed NC to\npediatric size. RR 50-70's with mild-mod SCR. BS clear and\nequal with upper airway congestion. Suctioned nares for mod\nwhite secretions.\n\n#9 Infant and well perfused. HR 150-160 +murmur.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-24 00:00:00.000", "description": "Report", "row_id": 1788745, "text": "Nursing Progress Notes.\n\n\n#2 O: Total fluids restricted to 130cc/kg/day of BM30 with\npromod. Feeds given every 4 hours over 40 . No spits or\nlarge aspirates. Bottle offered twice, 48 and 63cc taken.\nAbdomen soft, bowel sounds active, no loops, voiding well,\nno stool today, started on prune juice. 1x 2.5cc light\ngreen aspirate noted at 1730. J. Rivers aware. A:\nTolerating feeds well, learning to PO feed. P: Continue to\nencourage PO feeding and monitor for any feeding\nintolerance.\n#4 O: Temp stable in open crib. Baby is and active\nduring cares and bottle fed well. Baby sleeps well between\ncares swaddled in bed with head of bed elevated. A:\nAppropriate for age. P: Continue to support development.\n#5 O: Mother called for an update, unable to visit today.\nA: Involved family. P: Continue to keep informed and\nprovide immunization information at next visit.\n#8 O: Baby remained in nasal cannula oxygen 200cc flow, 50%\nuntil 1600 when baby began to wean down. Baby 1730 she was\nin 25% and had a large amount of secretions in her nose.\nNares were suctioned and cannula changed. Baby's sats were\n100% while cannula was out of her nose. Trial off oxygen\ngiven, Baby off oxygen for 1 hour. Baby now back in 200cc,\n60%. A: Trial off oxygen today. P: Continue to monitor and\nwean oxygen as tolerated.\n#9 O: Murmur not heard today. Baby pale , pulses\nnormal. A: Murmur not heard. P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-24 00:00:00.000", "description": "Report", "row_id": 1788746, "text": "Rehab/OT\n\nUpdated play plan. Infant sleeping on her back, ready for increased stimulation. Played in prone, sidelying, and sitting today. Plan posted at the bedside with new recommendations. Please refer to for details. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788747, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 63cc q4h. Infant bottled 63ccx1 so far this\nshift. Abdomen is benign, voiding. Infant had trace stools.\nGiven glyc. supp. Infant had large, heme neg stool. No\nspits. A: Tolerating feeds P: Encourage po feeds.\n\n#4 DEV S/O: In , maintaining temps. with cares.\nSucking on pacifier. Will need consent for 60 day . A:\nAGA P: Continue to support dev.\n\n#5 Parenting S/O: Mom called tonight. Asking appropriate\nquestions. A: Involved, loving. P: Continue to support and\nupdate.\n\n# S/o: Infant in NC 25-60% FiO2, 200cc. Infants lungs are\nclear with some upper airway congestion. RR 40-60's,\nsubcostal retractions. Infant on Diuril. HR 140's, appears\n well perfused. Murmer not audible. A: Stable P:\nContinue to support and monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788748, "text": "Neonatology- Physical Exam\n\n remains in NC 200cc 30%. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-25 00:00:00.000", "description": "Report", "row_id": 1788749, "text": "Neonatology\nWill defer to next week.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788502, "text": "Clinical Nutrition\nO:\n31 wk gestational age BG, AGA, now on DOL 2.\nBirth wt: 1370 g (~25th %ile); current wt: 1285 g (-25)(down ~6% from birth wt)\nHC: 27.25 cm (~10th to 25th %ile)\nLN: 40.5 cm (~25th to 50th %ile)\nLabs noted\nNutrition: TF @ 120 cc/kg/d. PN started on DOL 1; lipids also started DOL 1. Feeds started on DOL 0; currently @ 50 cc/kg/d PE 20, increasing 15 cc/kg/. Remainder of fluids as PN via PIV; projected intake for next 24 hrs from PN ~42 kcal/kg/d, ~1.4 g pro/kg/d, and ~2.1 g fat/kg/d. From EN: ~43 kcal/kg/d, ~1.3 g pro/kg/d, and ~2.2 g fat/kg/d. Glucose infusion rate from PN ~3.2 mg/kg/min.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Initial goal for EN is ~150 cc/kg/d PE/BM 24, providing ~120 kcal/kg/d, ~3.3 to 3.6 g pro/kg/d. Appropriate to start Vit E and Fe supps when feeds reach initial goal. PN is tapering as EN advances. Further increases in feeds as per growth and tolerance. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~ 1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-29 00:00:00.000", "description": "Report", "row_id": 1788503, "text": "Fellow note: physical exam\nAlert, active. Under double phototherapy. RRR S1S2 nl No murmurs. femorals palpable. Mild retractions. CTAB soft, NTND BS present. AFOF Tone and power AGA MAEW CR< 2 secs.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788531, "text": "NICU nursing Note 1900-0700\n\n\n#2 FEN\nWeight tonight 1370gm (+5). TF 150 cc/kg/day of BM24. PG fed\nover 45min. abd is soft, round, +BS, no loops, no spits, min\naspirates. Voiding and stooling (green, seedy, heme\nnegative). + fissure. tolerating feeds well, heme negative\nstools, continue to follow.\n\n#4 DEV\nTemp stable in servo isolette, weaned to off and swaddled.\nAlert and active with cares, sleeping well between. MAE,\nAFSF. Symmetrical tone. AGA. Continue to promote\ndevelopmental growth.\n\n#5 Parenting\nNo contact.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788532, "text": "Neonatology\nRA. No spells. Comfortable apeparing. Some sat drifts during night that have resolved. On caffeine. No murmur.\n\nWT 1370 up 5. ABdomen benign. Tolerating feeds at 150 cc/k/d of 24 cal. WIll advance to 26 cal this am and monitor tolerance.\n\nBili lights dced yesterday. Rbd planned for am.\n\nCOntinue resp monitoring and nutritional management.\n\nHUS this am shows no IVH.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788533, "text": "Neonatology\nSome spits so will hold on current cal for today.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-05 00:00:00.000", "description": "Report", "row_id": 1788665, "text": "NPN \n\n\n#2 FEN S/O: TF restricted to 130cc/k/d. Infant to get bm 30\nwith promod, 51cc q4h po/pg. Infant to po x1 per shift.\nInfant attempted to breast feed today. Infant did not latch\nwell today. Feedings gavaged. Abdomen benign, voiding and\n. No spits, no aspirates. A: Tolerating feeds. P:\nContinue to encourage po feeds.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive. Sleepy today. Sucking on pacifier. A: AGA P:\nContinue to support.\n\n#5 Parenting S/O: Mom in for 1300 cares, very independant.\nTalking to infant, breast fed. Mom a little anxious feels\nshe is not breast feeding well. Nurse explained to mom about\ninfants O2 requirements and infant tiring at times. A:\nInvolved, loving. P: Continue to support and encourage.\n\n#8 RESP/CV S/O: Infant remains in 500cc NC, FiO2 50-70%.\nLungs are clear, subcostal retractions. RR 60-90's. Infant\nhaving drifts, improved with O2 changes. No spells. HR\n160's. BP stable. A: Stable in NC. P: Continue to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-06 00:00:00.000", "description": "Report", "row_id": 1788666, "text": "Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on Fluid Restriction of\n130cc's/kg/day,rec.BM30 with Promode 51cc's gavaged over 1\nhr.Alt. po/pg feeds.Weight=2.365kg up 15 grams.Abd. soft,pos\nbs,no loops or spits,minimal aspirates,girth 25.5.Infant\nbottled x 1 and took the full volume with a yellow\nnipple.Infant voiding and .A:Tolerating Feeds\nWell.P:Cont. to assess tolerance of feeds and monitor weight\ngain.\n\nDEV:AFSO.Infant and active with cares,sleeping well\nb/t cares.Infant presently in open crib,swaddled with nested\nboundaries.Infant bringing hands to face and\nmouth,intermitently sucking on pacifier.Temp. maintained in\nopen crib.A:AGA P:Cont. to support growth and dev.\n\nParenting:No contact from thus far this\nshift.A/P:Cont. to update,educate,and support.\n\nRESP:Infant remains in Hi-flow o2.NC FIO2 70-80%,flow rate\n500cc's/.RR 30-60's however noted transient tachypnea\ninto the 80's with IC/SC retractions.LS remain clear and\nequal b/l.No spells thus far,drifts in sats o2 titrated to\nmeet o2 needs.A:Alt.Resp. d/t Prematurity P:Cont. to assess\nresp. status.\n\nCV:Infant appears and well perfused.HR 150-170.Audible\nmurmur.BP 69/35(46).Infant mottles with cares,cont's on KCL\nsupps.A:Stable P:Cont. to assess for cardiac compromise.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-16 00:00:00.000", "description": "Report", "row_id": 1788710, "text": "Neonatology NP Note\nPE\nSwaddled in open crib\nAFOF, small, sutures approximated\nvery mild subcostal retractions, and nasal stuffiness in NCO2, lungs with transmitted upper airway noise, lung bases clear\nRRR, no murmur, and well perfused\nabdomen soft, nontender, nondistended\nsymmetric tone, tone improved from 1 week ago when I examined last,\nskin without lesion or rash\nsome periorbital edema\n" }, { "category": "Nursing/other", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 1788637, "text": "NPN NOCS\n\n\n2. O: Wt 2255, up 50gms. TF remains at 130cc/kg of BM30 with\nPM. Gavaged over 40min. Bottled x1 took of bottle.\nVoiding, small stool. Abdomen benign. Small spit. No\nresidual. A/P: Continue with plan.\n\n4. O: Temp stable in open crib. Quietly and active\nwith cares. A/P: Continue to support dev needs.\n\n5. No contact from this shift.\n\n8. O: Received infant in NC 300cc flow with FiO2 75%. Infant\nnow in low flow 100% O2 at 150-175cc. RR 40-70's. LS clear.\nNo spells. A: Stable in current O2. P: Continue to monitor.\n\n9. O: Continues with soft murmur. and perfused.\nBP 70/38 48. HR 150-160's. A/P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 1788638, "text": "Neonatology Attending Progress Note\n\nNow day of life 31, CA 3/7 weeks.\nBaby continues to have a significant O2 requirement - currently 175cc of 100%.\nBaby has occasional episodes of desaturation noted during feedings.\nRR 40-70s.\nNo bradycardia noted.\n\nBP 70/38 48 HR 150-160s\n\nWt. 2255gm up 50gm on 130cc/kg/d of MM30 with Promod\nFeedings overall well tolerated po/pg - attempting breastfeeding.\nDoes have these episodes of desaturation with feedings.\n\nAssessment/plan:\nOne month old infant with persistant chronic lung disease. Possible CPIP. Question of GERD, may also be early presentation of less common diagnoses such as CF.\nWill discuss further treatments and possible further work-up if no improvement noted.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 1788639, "text": "Neonatology Attending Progress Note\n\nAddendum - PE\n\nBaby is centrally breathing with mild subcostal retractions.\nAF soft and flat.\nLungs clear - no rales or rhonchi, equal.\nCVS - S1 S2 normal - no murmur\nAbd - soft with no distension\nNeuro - sleeping during exam - tone appears appropriate\n" }, { "category": "Nursing/other", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 1788640, "text": "Nursing Progress Note\n\n\n1. FEN O/A TF=130cc/kg/day of BM30w/PM. Mom put inf to\nbreast for lact consult. Did well. Remainder of feedings\ngavaged. No spits, asp. Belly soft, no loops. Inf\nvoiding, . P cont to assess FEN needs.\n4. DEV O/A remains in an with stable temps.\nA/A with cares, sl lethargic. Mom states that baby is less\nsleepy than yesterday. P cont to assess.\n5. O/A Mom and in for visit and cares.\nUpdates given. Independent with care of infant. P cont to\nsupport, educate.\n8. Resp O/A Rec'dinf in NC. Inf ramains in NC 100%\n75-175cc thus far. 1X desat to 70's requiring BBO2 during\ngavage feeding. Baby prefers prone position. P cont to\nassess resp needs.\n9. CV O/A Soft murmur audible. Inf ins and well\nperfused. P cont to assess CV needs.\nSee flowsheet for further details.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-31 00:00:00.000", "description": "Report", "row_id": 1788641, "text": "Neonatology NP Note\nPE\nAFOF,sutures opposed\nmild-moderate subcostal retractions in NCO2,lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft, nontender, nondistended, active bowel sounds\nslightly decreased tone overall\nmild periorbital and pretibial edema\n" }, { "category": "Nursing/other", "chartdate": "2195-11-11 00:00:00.000", "description": "Report", "row_id": 1788687, "text": "Neonatology\nRemains in high flow NCO2. More comfortable apeparing. WIll considre addition of Diuril in am if lytes in reasonable range.\n\nWt 2630 up 65. Abdomen benign. Tolerating feeds better po with increased flow rate of O2.\n\nWill check Hct and retic with Lytes tomorrow.\n\nDr spoke with mother last night.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-11 00:00:00.000", "description": "Report", "row_id": 1788688, "text": "Neonatology- Physical Exam\n\n remains in NC 500cc. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, no retractions. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-11 00:00:00.000", "description": "Report", "row_id": 1788689, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 57cc q4h. Po x1 a shift. Infants abdomen is\nsoft, active bowel sounds, voiding. Infant had no stools\nthis shift. Getting K supps. A: Tolerating feeds P: Continue\nto monitor and encourage po feeding.\n\n#4 DEV S/O: Infant in , maintaining temps. with\ncares. Sucking on pacifier. A: AGA P: Continue to support\ndev.\n\n#5 Parenting S/O: Mom called in this am to check on infants\nrespiratory status. Mom updated. Asking appropriate\nquestions. A: Involved, loving P: Continue to support.\n\n#8 CV RESP status: Infant in NC 500cc, 55-65%. Infants lungs\nare clear with sc/ic retractions. RR 50-60's. Suctioned x2\nnasally for mod yellow. No spells. HR 150's. A: Stable in\nNC. P: Continue to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-11 00:00:00.000", "description": "Report", "row_id": 1788690, "text": "Clinical Nutrition\nO:\n38 wk CGA BG on DOL 45.\nWT: 2630g(+65)(~25th %ile); birth wt: 1370g. Average wt gain of past week ~18g/kg/d.\nHC: 33cm(~50th %ile); last wk: 31.75cm\nLN: 43.5cm(<10th %ile); last wk: 44cm\nMeds include Fe, vit E, & KCl\n due this week\nNutrition: 130cc/kg/d as BM 30 w/promod; po/pg on pump over 50mins. Average of past 3d intake ~131cc/kg/d, providing ~131kcals/kg/d & ~3.6g pro/kg/d.\nGI: Abdomen benign\nA/Goals:\nTolerating feeds without GI probs over extended feeding time; po/pg, po x1. due this week. Current feeds & supps meeting recommendations for kcals/pro/vits/mins. Growth is meeting recs for WT gain. HC gain slightly exceeding recs of ~0.5-1cm/wk. LN gain not meeting recs of ~1cm/wk. Will follow trends. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-23 00:00:00.000", "description": "Report", "row_id": 1788741, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=130cc/kg/day of BM30w/PM. Inf poor PO\nfeeding this shift. feeds well, no spits, asp thus\nfar. Belly soft, no loops. Infant voiding, no stool thus\nfar. P cont to offer PO feeds as .\n4. DEV O/A remains in an with stable temp.\nA/a w/cares. Eye exam today showed that eyes are now\nmature. P cont to assess dev needs.\n5. O/A Mom called for updates this am. P Mom\nplans to visit at 1700 cares. P cont to support, educate.\n8. Resp O/A Rec'd inf in NC 500cc. Inf currently in NC\n200cc 40-55% thus far. Continues on Diuril as ordered. P\ncont to assess resp needs.\n9. CV O/A Soft murmur aduible. Inf , well perfused.\nP cont to assess.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-06 00:00:00.000", "description": "Report", "row_id": 1788534, "text": "Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 9.\nWT: 1370 g (+5)(~10th to 25th %ile); birth wt: 1370 g. Infant has just re-achieved birth wt. Average wt gain over past wk ~9 g/kg/d.\nHC: 27.5 cm (<10th %ile); last: 27.25 cm\nLN: 40.5 cm (~10th to 25th %ile); 40.5 cm\nMeds include Fe and Vit E\nLabs not due yet.\nNutrition: 150 cc/kg/d BM/PE 24, pg over 45 min due to hx of spits. Feeds just increased recently; projected intake for next 24 hrs ~120 kcal/kg/d, ~3.3 to 3.6 g pro/kg/d.\nGI: Abdomen benign. Some small spits. One soft loop of bowel overnight; now resolved.\n\nA/Goals:\nTolerating feeds without GI problems over extended feeding time except small spits and transient loop as noted above. Feedings were not further advanced today due to above. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is not meeting recs for any parameter yet. Expect improvement in growth now that feeds are at initial goal. Will likely be further advancing kcals as soon as abdominal exam is completely benign. Will continue to follow w/team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 1788575, "text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. She is ruddy , well perfused, no murmur auscultated. She is comfortable in NCO2 50-125ccs/100%. Breath sounds clear and equal. No spells. she is tolerating full volume pg feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. HCt yesterday 47. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 1788576, "text": "Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 18.\nWT: 1655 g (+50)(~10th to 25th %ile); birth wt: 1370 g. Average wt gain over past wk ~20 g/kg/d.\nHC: 28.5 cm (~10th to 25th %ile); last: 27.5 cm\nLN: 42 cm (~10th to 25th %ile); last: 40.5 cm\nMeds include Fe and Vit E\nLabs not due yet.\nNutrition: 150 cc/kg/d BM 28 w/ promod, pg over 40 min. due to hx of spits. Average of past 3 d intake ~150 cc/kg/d, providing ~140 kcal/kg/d and ~4.1 g pro/kg/d.\nGI: Abdomen round and full; one small spit.\n\nA/Goals:\nTolerating feeds over extended feeding time without GI problems except small spit as noted above. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN gain is exceeding recommended ~1 cm/wk; will follow long term trends. Will continue to follow w/team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 1788577, "text": "NPN 0700-\n\n\n2.TF CONT. AT 150CC/K/D OF BM28 WITH PM. GAVAGING 41CC Q\n4HRS. TOLERATING WELL. SMALL SPIT X1. NO ASP. ABD SOFT, NO\nLOOPS, +BS. GIRTH 23CM. D/S 122. VOIDING AND STOOLING GUIAC\n- STOOL. PLAN; CONT. TO MONITOR TOLERANCE TO FEEDINGS.\nMONITOR WT, GAIN.\n\n4. REMAINS IN OAC. TEMPS STABLE. A/A WITH CARES. WAKING FOR\nALL CARES. MOVING ALL EXTREMETIES. ALL PG FEEDS. PLAN; CONT.\nTO SUPPORT G/D.\n\n5. NO CONTACT FROM TODAY.\n\n8. CONT. TO INCREASE O2 REQUIRMENT. REMAINS ON 100% LOW FLOW\n AT 125-150CC. LS CTA/=. REQUIRING BULB AND DEEP SX. CAP GAS\nDONE. BACK AT 7.27 61-33-29--1. WBC 14 WIH NO BANDS. HCT 47.\nBCX PNDING. RDV CX OBTAINED. ALSO PENDING. NOTED INCREASED\nWOB AT TIMES. NO INCREASED TACHYPNEA. DESATTING FREQUENTLY\nTO MID 80'S, MAINLY WITH FEEDING AND AFTER FEEDING HOB UP 45\nDEGREES. PLAN; CONT. TO MONITOR RESP. STATUS, MONITOR FOR\nINCREASED WOB. EKG FAXED TO .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-16 00:00:00.000", "description": "Report", "row_id": 1788711, "text": "NPN\n\n\n#2F/N O-Infant remains on Bm30cal w/promod at 130cc/kg.\nInfant breast fed well today when Mom in to visit. She\nbottled entire feed at 1700. Voiding well. Had large stool\nx1. A- Improving with feeds P- Follow wts.\n#4Dev. O- infant with stable temp in open crib. Infant\nsleeping supine with bed flat. Infant active and for\nMom and PM cares. A- corrected at 38 P- Support dev.\nNeeds eye exam per team.\n#5Family O-Mom in to visit and offering infant breast. Mom\n with cares. Mom aware that diuril dose\nincreased. Mom handles infant well Has very good\nsupply of BM P- Continue to support and teach.\n#8Resp O- Infant remains in NC 50-65% O2 500cc's with sats\n89-96. RR 40-70. Lungs clear. Mild retractions noted.TB sx\nfor old mucous plug. Color pale/. No spells noted.\nDiuril dose increased per team. A- Stable in NC P- Wean O2\nas . Check per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-17 00:00:00.000", "description": "Report", "row_id": 1788712, "text": "NPN\n\n\n#2FEN:\nO: Wt 2.665 (-40 gms) On 130cc/k/d BM 30 with prom. \ngavages well. no spits. bottled well but uncoordinated, (see\nresp) voiding qs. On diuril and KCL.\nA: Wt loss probably due to increased diuretic\nP: Cont to monitor growth. offer po's\n\n#4dev:\no: temps stable in open crib. and waking for cares.\ncrying between cares at times. Consoled with pacifier. AFSOF\nA/P: Cont. to support dev.\n\n#5Parenting:\nO: Mom called and given update\nA/P: Cont to support and inform.\n\n#8resp:\no: On cannula 500cc flow , 40% baseling to maintain sats in\n90-95 range. Color . RR 40-70, mild -mod IC/SC\nretractions. Desat and brady with po feeding. Difficulty\ncoordinating. needed stim and increased O2.\nA/P: Cont to monitor closely.\n\n#9CV:\no: Soft murmur noted\nA/P: Cont to monitor for compromise.\n\n#10: Thrush:\nO: Oral thrush noted on tounge. Nystatin oral susp. ordered\nand given. small monilial appearing rash on anus.\nA/P: Cont with tx.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-17 00:00:00.000", "description": "Report", "row_id": 1788713, "text": "Neonatology\nComfortable appearing without distress while lying aslepp. Lungs clear. Murmur soft, as before. ABdomen bneign. All 4 ext move well. Skin nl. Neuro age and state appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-17 00:00:00.000", "description": "Report", "row_id": 1788714, "text": "Neonatology\nDoing well. Remains in NCO2. SL decreased Fio2 over past 24 h. Doiruil increased yesterday. WIll continue to follow.\n\nWT 2665 down 40. Tolerating po 2x/shift. Doing well witrh this. Still req gavage. Abdomen bneign.\n\nCOntinue to await maturation of feeds and resp.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-29 00:00:00.000", "description": "Report", "row_id": 1788770, "text": "NPN Days\n\n\n#2 FEN: TF= 130cc/kg/day of BM 28 w/ promod Q 4hrs. Taking\nfull feeds plus breastfeeding X 20 . Abd benign. No\nspits. Voiding & . Heme neg. P: cont to monitor.\n#4G&D: Temps stable in open crib. Waking for feeds.\nSucking on pacifier. AGA. P: Will receive two remaining\nvaccines. cont to monitor.\n#5Parenting: Mom in today for cares X 1 & breastfeeding.\nAsking approp questions. Updates given. Mom very happy to\nsee off NCO2. P: cont to support & educate.\n#8Resp: Pt received in NCO2 200cc 21%. Trialed off to RA @\n8am. Pt cont on RA throughout shift. Lungs c&=. No\nspells, no drifting. Pt. cont on diuril. P: cont to\nmonitor.\nSee flowsheet for further details\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-09 00:00:00.000", "description": "Report", "row_id": 1788680, "text": "Neonatology- Physical Exam\n\n remains in NC 500cc. Active, in open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-09 00:00:00.000", "description": "Report", "row_id": 1788681, "text": "Nursing note\n\n\n#2 FEN O: Child remains fluid restricted at 130cc/k of BM 30\nwith promod. Child on an alternating po/pg feeding schedule.\nGavaged at 0930 aver 1 hour. tolerated gavage feed without\nspits or aspirates. Bottled with the yellow nipple at 1300.\nTook whole feeding in about 20 minutes. Child tired at the\nend. Increased fio2 to 100 percent during feeding. Abdomen\nremains benign. Good bowel sounds heard. No loops noted.\nChild voiding and well. P: Will continue on alt.\npo/pg schedule and will monitor resp effort and weight gain.\n#4 G+D O: Child remains in open crib. Temp stable. Mostly\nsleeps between feeds. Will wake for some feeds. P: Will\ncontinue to support the child's coping skills.\n#5 Parenting O: mom called once today. Given status update.\nASked aprropriate questions. P: Will continue to support and\ninform the .\n#8 Resp O: Child received on 400cc and 70-80 percent. Child\nhad mild to moderate inter and subcostal retractions. Some\nWOB noted at rest. and MD aware. Increased child to\n500cc flow. Child had decreased WOB after increased flow.\nBreath sounds are clear and equal. Child does have some\nnasal congestion. Child suctioned for moderate to large\namount of white mucus. RR as noted in flow sheet. No head\nbobbing or flaring noted during feed with increased flow and\nfio2 at 100 percent. P: Will continue to monitor WOb\nclosely and support as needed.\n#9 CV O: Child continues to have murmur. No pulses\nnoted. Cap refill brisk. P: Will continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-20 00:00:00.000", "description": "Report", "row_id": 1788726, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=130cc/kg/day of BM30w/PM. Inf PO feeding\n45-65cc this shift. well. No spits, asp thus far.\nBelly soft, no loops. Inf voiding, no stool thus far. P\ncont to offer PO feeds as .\n4. DEV O/A remains in an with stable temp.\nA/A w/cares, waking for some cares. Sucks pacifier. P cont\nto assess dev needs.\n5. O/A No contact thus far. P cont to support,\neducate.\n8. Resp O/A Rec'd inf in NC. Inf remains in NC 500cc\n45-60cc this shift. SX 1X for lg plugs and clear secretions\nafter infant had been sneezing. New NC applied. P cont to\nassess resp needs, wean O2 as .\n9. CV O/A Murmur audible, inf well perfused. P cont\nto assess CV needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-20 00:00:00.000", "description": "Report", "row_id": 1788727, "text": "Neonatology Attending Note\nDay 54\nCGA 39 3\n\nNC 500cc, 40-50%. RR30-60s. No A&Bs. On diuril and kcl. +Soft murmur. HR 140-160s. BP 77/36, 51.\n\nWt 2805, up 20. TF 130 cc/k/day BM30 w promod. PO/PG. PO skills improving.\n\nIn open crib.\n\nA/P:\nWean O2 as \nNo change to diuril and K\nNo change to nutritional plan\n" }, { "category": "Nursing/other", "chartdate": "2195-11-24 00:00:00.000", "description": "Report", "row_id": 1788742, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF restricted at 130cc/k/d. Infant to get bm 30\nwith promod, 63cc po/pg q4h. Infant bottled 63 and 33cc so\nfar this shift. Abdomen is benign, voiding. No stools on\nthis shift. No spits, . aspirates. On KCL supps. A:\nStable P: Continue to support.\n\n#4 DEV S/O: Infant in , maintaining temps. and\nactive. Waking for some feeds. On vit e and iron. A: AGA P:\nContinue to support dev.\n\n#5 Parenting S/O: Mom called x 2 tonight. Updated on infants\nweight and po intake. Asking appropriate questions. A:\nInvolved, loving. P: Continue to support and update.\n\n#8 RESP/CV S/O: Infant in NC 200c, 40-60%. Lungs sounds are\nclear with somw upper airway congestion. RR 40-60's,\nsubcostal retractions. On diuril. HR 140-160's, infant\nappears , well perfused. No spells tonight, drifting\ninto 80's. A: Stable in NC. P: Continue to monitor and wean\no2 as tolerated.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-24 00:00:00.000", "description": "Report", "row_id": 1788743, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, soft murmur auscultated. She remains in NCO2 200ccs/40-60%. Breath sounds clear and equal. Remains on diuril. She is tolerating po/pg feeds. Abd soft, active bowel sounds, no loops. Voiding, no stool last night. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-24 00:00:00.000", "description": "Report", "row_id": 1788744, "text": "Neonatology\nDoing well. Remains in NCO2 200 cc 40-60%. No spells. Comfortable appearing.\n\nOn diruil Lytes rto be checked on Thursday.\n\nAttempted to schedule ba swallow to assess for possibiulity of reflux/aspiraion.\n\nWt 2885 down 45. Tolerating efeds SAtill req gavage.\n\nStarted on prune juice.\n\nSpoke with mother by phone yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2195-09-28 00:00:00.000", "description": "Report", "row_id": 1788496, "text": "Neonatology\nRA. No spells. Comfortable apeparing. No murmur.,\n\nWt 1310 down 60. Tf at 100 cc/k/d. Abdomen benign.\nTolerating feeds at 20 cc/k/d. WIll continue feeding advancement.\nWIll start PN.\n\nMild jaundice. Bili in 6 range. Photorx to begin. Recheck in am.\n\nHUS at end of week.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-16 00:00:00.000", "description": "Report", "row_id": 1788578, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get bm 28 with pm, 41cc\nq4h pg. Infant has had no spits, minimal aspirates. Abdomen\nis benign, voiding and stooling. Getting Criticaid to\nbottom. A: Tolerating pg feeds. P: Continue to monitor and\nencourage some po feeding.\n\n#4 DEV S/O: Infant maintaining temps in OAC. Alert and\nactive with cares. Not waking before cares. Sucking on\npacifier. A: AGA P: Continue to support.\n\n#5 Parenting S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#8 RESP S/O: Infant in NC, Fio2 100%, 125-150cc. Infants\nlungs are clear with sc/ic retractions. RR 50-80's. No\nspells. Frequent drifts into the high 80's. A: Stable in NC.\nP: Continue to monitor and wean o2 as tolerated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-16 00:00:00.000", "description": "Report", "row_id": 1788579, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, grade murmur audible. and well perfused. ABd benign, no HSM. Active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2195-10-26 00:00:00.000", "description": "Report", "row_id": 1788620, "text": "0700- NPN\n\n\nRESP: Cont on NC 100% 75-125cc flow rate (increased as high\nas 200cc flow during cares and BF). RR 40's-70's, O2 sats\n88-96%. LS clear/=. Mod IC/SC retractions noted. No\nbradys. Occasional desats to low 80%'s that require\nincrease in O2 or are QSR. Pt does not tolerate supine or\nside lying positions well. P: Cont to monitor and wean O2\nas tolerated.\n\nFEN: TF decreased from 150cc/kg/d to 130cc/kg/d d/t resp\nstatus. Pt receiving BM28 with PM (44cc Q4hr) PO/PG. Pt BF\nx 1 this shift for < 5 mins, latch on x 2, eager to suck.\nNo spits. Minimal aspirates. Abdomen benign. Pt voiding,\n (heme-). Cont on Ferinsol and Vit E. P: Cont to\nmonitor and encourage PO feeding as tolerated.\n\nDEV: Temps stable in , pt dressed/swaddled. MAE,\n/active with cares. Sleeps between cares, not yet\nwaking independently for feeds. Sucks pacifier and brings\nhands to face for comfort. Fontanels soft/flat. AGA. P:\nCont to support growth and development.\n\nPARENTING: Mom in to visit for 1300 care, updated by RN,\nasking appropriate questions. Mom participated in care and\nheld/BF infant. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-27 00:00:00.000", "description": "Report", "row_id": 1788621, "text": "NPN\n\n\n#2 F/N- Abd soft,+bs, no loops.Tolerating feeds of BM 28\ncals w/Promod w/o spits. Minimal asps.Wt up 50gms.Bottled x1\n35cc out of 44cc q 4 hrs.Ng feeds given on a pump over 40\nmins.Voiding+ in adeq amts.TF= 130cc/kg/day.\n#5 -No contact tonight.\n#8 Resp- Remains in NC 100% o2 in 50-100cc. RR= 30-70. Mild\nretractions.Sxn x1 for mod amts.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-10-27 00:00:00.000", "description": "Report", "row_id": 1788622, "text": "Neonatology Attending Note\nDay 30\n\nCGA 36\n\nNC 50-125cc, 100%. RR40-70s. Mod secretions. Cl and =. +Int murmur (ECHO nl). Mean BP 53.\n\nWt 2075, up 50 g. TF 130 cc/k/day BM/PE28 w promod. po/pg. Nl voiding and .\n\nIn open crib.\n\nFe and Vit E.\n\nA/P:\n - exact etiology of delayed O2 req. unclear. cardiology eval negative. minimal response to lasix last week. currently on fluid restriction.\n - monitor growth, encourage po skills\n - check lytes again to monitor alkalosis\n - due for 1 month HUS\n" }, { "category": "Nursing/other", "chartdate": "2195-11-30 00:00:00.000", "description": "Report", "row_id": 1788771, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >92%. NOTED A FEW QUICK TO 87 IMMEDIATELY AFTER 0100 FEEDING, HOB ELEVATED AND NO FURTHER NOTED FOR REMAINDER OF SHIFT. BS CL&= WITH NO INCREASE IN WORK OF BREATHING. NO MURMER, COLOR PALE/ WITH GOOD PERFUSION THROUGHOUT. NO A&B'S ALL SHIFT.\n\nFEN: WEIGHT 3075GMS, UP 20GMS. BOTTLING 70-75CC VIGOROUSLY. VOIDING AND WNL. ABD SOFT, WITH +BS AND NO LOOPS OR EMESIS.\n\nDEV: TEMP STABLE IN OPEN CRIB. RECEIVED DTP AND PREVNAR VACCINES TONIGHT WITH TYLENOL FOR COMFORT X1.\n\nSOCIAL: MOM CALLED FOR UPDATE, VERY EXCITED ABOUT PROGRESS. WILL VISIT AT 1PM TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-30 00:00:00.000", "description": "Report", "row_id": 1788772, "text": "Neonatology\nDoing well. RA since yesterday am.. No spells. Comfortable appearing.\n\nWt 3075 up 30. TF at minimum 130 cc/k/d. Abdomen benign. Will decrease to 26 cal.\n\nSynagis consent to be obtained.\nLytes and Hct to be checked.\nCar test to be done.\nHearing screen passed.\n\nHave call into pulmonary for discharge follow-up. Dr will see on Wednesday.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-11-30 00:00:00.000", "description": "Report", "row_id": 1788773, "text": "Case Management Note\nTeam anticipating home d'c Wednesday and referral called in today to VNA (). They will be able to see baby for 1st home visit day . Referral will need to be faxed to on day of d'c. If d'c is delayed, please call VNA to reschedule. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2195-11-30 00:00:00.000", "description": "Report", "row_id": 1788774, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nREsp\nO: remains in room air, RR 40-60's, sat's >93%. No\ndrifts or spells. BSCE bilat. A: Breathing comfortably. P:\nCont to follow.\nFEN\nO: TF of 130cc/k/d of BM 26, bottling well today taking\n65-70cc. Mom in and baby latch / bf for 5\".Abd , no\nloops, active bs. Voiding / . No spits. A: Stable.\np: cont to follow.\nGD\nO: temp stable in , active and with cares. MAE.\nFont soft, flat. A: Stable. P: cont to support dev.\nmilestones.\nParenting\nO: Mom in and updated, verbalizing understanding. Ongoing dc\nplan, possible Wednesday. A: Involved and loving . P:\ncont to update, support, and educate.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-10-06 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 802827, "text": " 7:27 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 31 weeks, now 7 days old\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Ex-31-week infant, now nine days of age.\n\n Sulci, gyri and ventricles are symmetric and normal in size for the patient's\n age. No extraaxial collection or hemorrhage is identified. Midline\n structures appear normal.\n\n IMPRESSION: Normal head ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2195-09-30 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 802296, "text": " 5:27 PM\n PORTABLE ABDOMEN Clip # \n Reason: evalaute bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with distended abdomen, bilious aspirates\n REASON FOR THIS EXAMINATION:\n evalaute bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE KUB ON AT 18:30:\n\n HISTORY: Three day old girl with a distended abdomen and bilious aspirates.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: An enteric tube with the tip projected over the stomach. There are\n several, air-filled, prominent loops of bowel throughout the abdomen. This\n includes air in the rectum. There is no convincing evidence for pneumatosis,\n or wall-thickening. A heterogeneous appearance of the left abdominal bowel\n gas pattern is likely related to overlapping loops, rather than pneumatosis.\n No evidence for portal venous gas.\n\n The basilar lungs show a mildly hazy appearance with a few linear densities.\n This could represent mild hyaline membrane disease or the normal appearance of\n premature lungs with superimposed areas of sugsegmental atelectasis.\n\n IMPRESSION: Non-specific bowel gas pattern with several mildly prominent\n loops throughout the abdomen. There are no specific signs of necrotizing\n enterocolitis.\n\n RECOMMENDATION: If there is clinical concern for midgut volvulus, would\n recommend further evaluation with an UGI series.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-10-22 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 804414, "text": " 12:47 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields, Please do xray at 1:00 AM\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, increased FiO2 requirement\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n Please do xray at 1:00 AM\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Premature infant with increased FIO2 requirement.\n\n CHEST: The nasogastric tube is present with the tip in the stomach. The lungs\n demonstrate normal volume but increased hazy bilateral opacity which is\n progressive when compared to the film of . More focal, confluent\n opacity is especially seen within the left upper lobe.\n\n IMPRESSION: Progressive bilateral pulmonary opacity likely representing\n worsening microatelectasis.\n\n" }, { "category": "Echo", "chartdate": "2195-10-23 00:00:00.000", "description": "Report", "row_id": 75606, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease. PDA.\nStatus: Inpatient\nDate/Time: at 12:31\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric case. Report to be generated at .\n\n\n" }, { "category": "Radiology", "chartdate": "2195-10-28 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 804992, "text": " 7:13 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: INFANT BORN AT 31 WEEKS, NOW 1 MONTH OLD, R/O PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 31 weeks, now 1 month old\n REASON FOR THIS EXAMINATION:\n r/o PVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Former 31 week premature infant who is now one month of age.\n\n NEONATAL HEAD ULTRASOUND: Standard coronal and sagittal images of the brain\n were obtained via the anterior fontanel with additional mastoid views\n performed. The ventricles and extra-axial CSF spaces are within normal limits\n for the patient's chronologic and gestational age. The sulcal and gyral\n patterns are within normal limits. No structural abnormalities are present.\n No abnormal areas of increased echogenicity are seen.\n\n When compared to the previous examination of , there has been no\n interval change.\n\n Normal neonatal head ultrasound with no evidence for hemorrhagic or ischemic\n change. No hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2195-11-03 00:00:00.000", "description": "RENAL U.S. (PORTABLE)", "row_id": 805548, "text": " 7:21 AM\n RENAL U.S. (PORTABLE) Clip # \n Reason: INFANT WITH METABOLIC ALKALOSIS, LATE ONSET RESPIRATORY DISTRESS, EVALUATE KIDNEYS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with metabolic alkalosis, late onset respiratory distress\n REASON FOR THIS EXAMINATION:\n evaluate kidneys\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND:\n\n HISTORY: Infant with metabolic alkalosis. Late onset respiratory distress.\n Evaluate kidneys.\n\n FINDINGS: Both kidneys are normal in position, shape, cortical thickness and\n echo texture. There is minimal right pelvic fullness. There is no\n abnormality of the left renal collecting system. The kidneys each measure 4.1\n cm in length. The urinary bladder is empty and its appearance is\n unremarkable.\n\n IMPRESSION: Minimal right pelvic renal fullness. Normal appearing left\n kidney. Empty urinary bladder.\n\n" }, { "category": "Radiology", "chartdate": "2195-10-23 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 804558, "text": " 12:51 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: assess lung fielsd & heart size, , remains in O2 with soft\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n please do at ~12:45 today\n Thanks!\n REASON FOR THIS EXAMINATION:\n assess lung fielsd & heart size\n\n remains in O2 with soft murmur\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate lung fields.\n\n FINDINGS: A single frontal portable view of the chest was performed on\n . This study was made available for interpretation on .\n Since , there has been little, if any interval change in the\n appearance of the chest. Hazy opacification throughout both lungs is seen, in\n the setting of relatively normal lung volumes. Differential diagnosis\n includes surfactant deficiency, or diffuse pneumonia. Nasogastric tube\n remains in the stomach. No acute abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2195-10-30 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 805226, "text": " 11:56 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: monitor lung fields, r/o infiltrates, infusion, progression\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with late-onset lung dz and O2 requirement (cardiac evaluation w/ ECHO\n negative).\n REASON FOR THIS EXAMINATION:\n monitor lung fields, r/o infiltrates, infusion, progression of dz\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n Comparison is made with the exam done on . There has been little change.\n The nasogastric tube reaches the stomach. The lung volumes are somewhat low,\n which probably accounts for most of the density in both lungs. There is\n probably mild chronic lung disease.\n\n" }, { "category": "ECG", "chartdate": "2195-10-15 00:00:00.000", "description": "Report", "row_id": 193719, "text": "Sinus tachycardia. Tracing is within normal limits for a newborn.\n\n" } ]

[ { "category": "ECG", "chartdate": "2188-05-31 00:00:00.000", "description": "Report", "row_id": 209559, "text": "Resting sinus tachycardia. Non-specific ST-T wave changes. Compared to the\nprevious tracing of , which showed sinus bradycardia, the heart rate\nis much faster and non-specific ST-T wave changes are now noted. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2188-06-01 00:00:00.000", "description": "Report", "row_id": 1301100, "text": "MICU NURSING NOTE 7p-7a\nPLEASE SEE CAREVIEW FOR SUBJECTIVE DATA AND PERTINENT LABS:\n\n\n56 YO OLD MALE WITH A H/O OF HEP C; NEW DIAGNOSIS OF SMOLDERING MYELOMA , EARLY ENCEPHALOPATHY,THROMBOCYTOPENIA SPELENOMEGALY,DUODENAL ULCER.. PRESENTED TO THE EW W/SOB, LETHARGY, MENTAL STATUS CHANGES, HYPOXIC, HYPOTENSIVE IN THE 80S; LACTATE 15.4;PT. RECEIVED 7L IVF; STARTED ON LEVOPHED;SEPSIS PROTOCOL; TRANSFERRED TO MICU FOR FURTHER MANAGEMENT;UPON ARRIVAL TO THE MICU TEAM SPOKE WITH FAMILY ABOUT CODE STATUS AND THE DECISION WAS MADE BY HIS WIFE TO MAKE HIM A DNR . IN THE MICU PT. REQUIRED A SECOND PRESSOR, SBP PERSISTENTLY IN THE 80S,UNTIL COULD NO LONGER BE OBTAINED; PH OF 6.88. MD SPOKE WITH FAMILY AND THE DECISION WAS MADE TO WITHDRAW CARE. PT. WAS PLACED ON A MORPHINE AND ATIVAN DRIP AND WAS EXTUBATED ~ 3:20,FAMILY AT BEDSIDE WHEN PT. PASSED ~3:30.\n" }, { "category": "Radiology", "chartdate": "2188-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916353, "text": " 7:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fever, hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:00 \n\n HISTORY: Fever and hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are much lower in volume, accounting for some interval increase in heart\n size. The azygos vein is distended and there is a suggestion of mild edema in\n the right lung, but the combination of hypotension and large heart raises\n concern for pericardial effusion and cardiac tamponade. There is no\n appreciable pleural effusion. Lateral aspect of the left chest is excluded\n from the examination. Other pleural surfaces give no indication of\n pneumothorax.\n\n Findings on this film and the one performed at 8:55 p.m. after intubation and\n line placement were discussed with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 916360, "text": " 8:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: DELTA MS CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with delta ms\n REASON FOR THIS EXAMINATION:\n please eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd SAT 11:21 PM\n no acute ich or change from prior\n mri with diffusion weighted images is more sensitive in the evaluation for\n acute ischemia/infarct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change in mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: No evidence of acute intracranial hemorrhage. There is no shift of\n normally midline structures. Again seen is a cavum septum pellucidum\n unchanged from prior study. The ventricles appear unchanged from prior study.\n -white matter differentiation appears grossly preserved, and there is no\n evidence of major vascular territorial infarct. Visualized paranasal sinuses\n appear normally aerated.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or change from prior\n study. MRI with diffusion-weighted images more sensitive in the evaluation\n for acute ischemia/infarct.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916361, "text": " 8:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fever, hypotension s/p intubation\n\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:55 \n\n HISTORY: Fever, hypotension, status post intubation.\n\n IMPRESSION: AP chest compared to 7:00 p.m.:\n\n Tip of the new endotracheal tube is at the upper margin of the clavicles\n between 4 and 5 cm from the carina. Tip of the new left internal jugular line\n projects over the course of the left brachiocephalic vein. Lungs are\n appreciably lower in volume and there is generalized widening of the\n mediastinum probably due to volume resuscitation, since there is new edema in\n the right upper lobe. There is no pneumothorax or appreciable pleural\n effusion.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2183-12-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 548416, "text": "Pt is a 76 yo s/p MVC related to hypoglycemic episode who sustained\n multiple cervical fractures and ligament injury. S/p cervical fusion on\n . To ICU post-op due to pressor requirement and facial edema form\n prone positioning intra-op.\n Hyperglycemia\n Assessment:\n Pt on insulin gtt since OR. BG 80-200s with gtt titrated accordingly.\n Pt MS very sensitive to elevated glucose levels and occ has associated\n confusion/restlessness. Reorients easily, pt is also most likely\n confused at times from sleep deprivation.\n Action:\n Lantus 20u given with reg insulin recommendations. Few hours\n later Gtt off. Freq BG checks and transitioned to AC/HS sliding scale.\n Response:\n BG checked several times, last check before dinner was 170. Reg insulin\n given.\n Plan:\n If BG >200 recommends additional 10u Lantus this evening.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n No motor deficits. OOB to chair with min-mod assist of 2. Alignment\n maintained with collar. C/o pain x2. JP drain removed by .\n Incision approximated with scant drainage.\n Action:\n Percocet given for pain.\n Response:\n Pt pain 0/10 after medication.\n Plan:\n Cont PRN pain meds. Cont collar at all times. Activity as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3 mostly. Does have periods infrequent periods of mild confusion\n . Example- occ asking where is his bed though his in his chair next to\n it. However pt knows he is in the hospital, can run down all meds and\n diabetic regimen etc.\n Action:\n Reorient as needed. Close monitoring of BG and appropriate insulin\n coverage.\n Response:\n Plan:\n Cont to monitor glucose closely. Promote sleep.\n" }, { "category": "Nursing", "chartdate": "2183-12-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 548418, "text": "Pt is a 76 yo s/p MVC related to hypoglycemic episode who sustained\n multiple cervical fractures and ligament injury. S/p cervical fusion on\n . To ICU post-op due to pressor requirement and facial edema form\n prone positioning intra-op.\n Hyperglycemia\n Assessment:\n Pt on insulin gtt since OR. BG 80-200s with gtt titrated accordingly.\n Pt MS very sensitive to elevated glucose levels and occ has associated\n confusion/restlessness. Reorients easily, pt is also most likely\n confused at times from sleep deprivation.\n Action:\n Lantus 20u given with reg insulin recommendations. Few hours\n later Gtt off. Freq BG checks and transitioned to AC/HS sliding scale.\n Response:\n BG checked several times, last check before dinner was 170. Reg insulin\n given.\n Plan:\n If BG >200 recommends additional 10u Lantus this evening.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n No motor deficits. OOB to chair with min-mod assist of 2. Alignment\n maintained with collar. C/o pain x2. JP drain removed by .\n Incision approximated with scant drainage.\n Action:\n Percocet given for pain.\n Response:\n Pt pain 0/10 after medication.\n Plan:\n Cont PRN pain meds. Cont collar at all times. Activity as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox3 mostly. Does have periods infrequent periods of mild confusion\n . Example- occ asking where is his bed though his in his chair next to\n it. However pt knows he is in the hospital, can run down all meds and\n diabetic regimen etc.\n Action:\n Reorient as needed. Close monitoring of BG and appropriate insulin\n coverage.\n Response:\n Plan:\n Cont to monitor glucose closely. Promote sleep.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Code status:\n Full code\n Height:\n Admission weight:\n 100.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: whipple procedure (creon/insulin)\n Surgery / Procedure and date: Admitted to T/SICU post surgical,\n C1-C2 fusion with oligraft of rt hip Remains in collar. Urine output\n low during OR. Considerable blood loss (EBL 1L), 2units packed cells\n given and 6400cc crystalloid\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:132\n D:65\n Temperature:\n 99\n Arterial BP:\n S:150\n D:61\n Respiratory rate:\n 23 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 98% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,682 mL\n 24h total out:\n 2,005 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 01:57 AM\n Potassium:\n 3.4 mEq/L\n 01:57 AM\n Chloride:\n 105 mEq/L\n 01:57 AM\n CO2:\n 28 mEq/L\n 01:57 AM\n BUN:\n 30 mg/dL\n 01:57 AM\n Creatinine:\n 1.5 mg/dL\n 01:57 AM\n Glucose:\n 86 mg/dL\n 01:57 AM\n Hematocrit:\n 26.3 %\n 01:57 AM\n Finger Stick Glucose:\n 170\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: \n Transferred to: 11\n Date & time of Transfer:\n" }, { "category": "Respiratory ", "chartdate": "2183-12-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 548140, "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: Yes\n Tube Type\n ETT:\n Position: 24 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: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\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: Pt. weaned overnoc to IPS . RSBI 74 this am, plan\n extubation.\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548141, "text": "TITLE:\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n J intact. Pt inconsistantly follows commands ( sedation),\n moves all extremities-localizes with UE\ns, and lifts LE\ns off bed.\n PERRLA 2-3mm/brisk. +scleral edema, though it appears as though\n corneals are intact. Cough improving, gag remains intact. Unable to\n assess sensation in extremities due to sedation. Pain appears to be\n controlled.\n Action:\n Neuro exam monitored, Dilaudid ivp for pain control and Midazolam for\n sedation.\n Response:\n After Dilaudid pt less restless, neuro exam still intact. Pt less\n hypotensive with Midazolam.\n Plan:\n Continue Q2 neuro exams-notify team of any changes, assess and treat\n pain/anxiety as indicated.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Intubated overnoc. due to facial swelling post op. Facial edema has\n gradually decreased throughout the night, gag improving. No secretions\n present per ETT. O2 sats 100%. RR 25-30.\n Action:\n Vent weaned to CPAP 5/5 on 40%. ABGs followed closely.\n Response:\n ABGs also showing more than adequate oxygenation. RSBI 74.\n Plan:\n Extubate this am.\n OVERNIGHT EVENTS:\n *weaned off Levophed\n Map remains >60 even with sedation.\n *Vigileo initiated, SVV 15-24, CO 6.0, CVP 6-12.\n *Creat remains elevated at 1.7, u/o improving, 15-45cc/hr.\n *Surgical incison site WNL, JP with min output.\n" }, { "category": "Nursing", "chartdate": "2183-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548122, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt. is fully vented. TV 500 O2 50% Rate 14 Peep 5 Breathing\n above vent, 5-10 breaths. Breath sounds clear to rhonchorous, suctioned\n for small amts of thick white to yellow secretions. Sats 95-98%,\n adequate abg.\n Action:\n Pulm hygiene per T/SICU Monitor sats and abg\ns as needed. Restrain as\n needed to protect airway.\n Response:\n Good pulmonary status. Continued gd sats. Patent airway.\n Plan:\n Cont. pulm hygiene. Plan in am for possible wean of vent. Pt. was\n intubated fiberoptically, maintain airway until scheduled extubation\n per team.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n Pt. had cervical surgery today, C1-2 fusion. Will remain sedated\n tonight. J collar in place. Collar care done. Remains flat in\n bed, slight reverse Tberg\n Action:\n Maintained in flat position. BP to be maintained with levo gtt as\n needed to maintain MAP 60. Monitor U/O\n Response:\n Cervical stability in collar. Adequate MAP.\n Plan:\n Adequate recovery from surgery, stable vs, weaned from pressors\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548213, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt arousable this am, agitated and attempting to self extubate.\n Incosistntly FCs. +gag, +cough. Adeq sats and PaO2 on PS 5/5 and 40%.\n Lungs clear with small amts thick tan secretions.\n Action:\n Extubated at 0800. Placed on 40% open face tent.\n Response:\n Pt lungs clear to rhonchorous. Cough improved over shift as MS improved\n and able to now cough and expectorate sputum with yankuer. Using IS at\n times though still somewhat lethargic. O2 removed as it was further\n agitating pt, RA sats 95-97%.\n Plan:\n Cont pulmonary toileting and IS.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n Collar in place. MAEs with good strength. Sensation intact. Posterior\n incision with intial post-op dressing intact. Serosanginous drainage.\n JP with sanginous output in small amts. Bone donor site on R iliac\n crest with intact sutures. Serosang drainage and dressing changed this\n am. This evening pt given liquids and swallowed without signs of\n aspiration.\n Action:\n Collar maintained.\n Response:\n Compliant.\n Plan:\n Maintain collar. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548135, "text": "TITLE:\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2183-12-07 00:00:00.000", "description": "Intensivist Note", "row_id": 548136, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n .\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Acetaminophen, Amlodipine, Atorvastatin, Bisacodyl,Calcium Gluconate,\n Chlorhexidine Gluconate, Creon 10, Docusate, Famotidine, Gentamicin,\n HYDROmorphone (Dilaudid), Hydrochlorothiazide, Insulin, Influenza Virus\n Vaccine, Magnesium Sulfate, Metoprolol Tartrate, Midazolam,\n Pneumococcal Vac Polyvalent, Propofol, Senna, Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:45 PM\n OR RECEIVED - At 04:50 PM\n ARTERIAL LINE - START 05:00 PM\n MULTI LUMEN - START 07:07 PM\n Left subclavian\n URINE CULTURE - At 10:51 PM\n BLOOD CULTURED - At 02:51 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Gentamicin - 09:38 PM\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 11:14 PM\n Hydromorphone (Dilaudid) - 12:13 AM\n Other medications:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.6\nC (99.6\n HR: 96 (68 - 106) bpm\n BP: 108/53(70) {74/48(62) - 146/69(94)} mmHg\n RR: 27 (19 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 15) mmHg\n Total In:\n 8,204 mL\n 594 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,504 mL\n 594 mL\n Blood products:\n 700 mL\n Total out:\n 1,230 mL\n 198 mL\n Urine:\n 160 mL\n 178 mL\n NG:\n Stool:\n Drains:\n 55 mL\n 20 mL\n Balance:\n 6,974 mL\n 396 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): 490 (490 - 490) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.38/37/150/24/-2\n Ve: 15 L/min\n PaO2 / FiO2: 375\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, c-collar\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 Moves all extremities, Sedated\n Labs / Radiology\n 156 K/uL\n 10.7 g/dL\n 183 mg/dL\n 1.7 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 106 mEq/L\n 136 mEq/L\n 30.2 %\n 21.6 K/uL\n [image002.jpg]\n 04:22 AM\n 05:03 PM\n 05:15 PM\n 01:20 AM\n 01:26 AM\n 04:18 AM\n WBC\n 22.8\n 17.0\n 21.6\n Hct\n 43.9\n 30.7\n 30.2\n Plt\n 290\n 162\n 156\n Creatinine\n 1.3\n 1.6\n 1.7\n TCO2\n 24\n 23\n 23\n Glucose\n 142\n 202\n 183\n Other labs: PT / PTT / INR:13.5/24.3/1.2, Differential-Neuts:79.9 %,\n Lymph:10.3 %, Mono:9.2 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca:7.4\n mg/dL, Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), CERVICAL FRACTURE (WITHOUT SPINAL CORD INJURY),\n TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 dens fracture and C4\n fracture, s/p Operative fusion.\n 24 HOUR EVENTS:\n OR for C1/2 fusion, hypotensive requiring double pressors\n (peripherally)in OR\n weaned off levophed and propofol changed to midazolam, uop increased\n once levo off\n t 100.8--> am cxr, UA/cx sent, blood cx.\n Neurologic: Neuro checks Q: 1 hr, s/p C1-2 fusion, cont collar. cont\n neuro checks: moving all 4 ext when sedation decreased.\n Cardiovascular: hypotensive. diff dx includes septic (Tm 100.8 pod#1,\n no infectious source, +wbc 17), neurogenic (c-spine\n surgery/manipulation today, no tachycardia with hypotension) and\n hypovolemic (extensive blood loss in OR, now s/p 6L crystalloid, 2u\n prbcs, crit 30). CVL: 10. UOP:~20cc/hr. wean levo (currently off), goal\n map >60. follow uop, cvl, ci. follow crit.\n Pulmonary: intubated, ETT advanced 3cm s/p cxr. on cpap/ps, plan for\n extubation this am. rsbi: 74\n Gastrointestinal / Abdomen: no active issues. no NG/OG place overnight\n Nutrition: NPO\n Renal: Foley, Cr 1.1--> 1.6, no hx of RI, likely pre-renal intraop,\n follow uop and Cr. uop adequate since levophed d/ced\n Hematology: Hct 30, stable\n Endocrine: Insulin drip, cont insulin drip\n Infectious Disease: wbc elevated 17; fever post-op to 100.8: follow up\n UA/cx, blood cx, am cxr. continue vanc/gent per nsurg\n Lines / Tubes / Drains: L subclavian CVL (), PIV, foley, unable to\n place NGT overnight\n Wounds: R hand lac sutured, extensive surrounding bruising, small head\n lac\n Imaging:\n Fluids: then D51/2NS @ 80ml/hr, D10W 10 cc/hr\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Vertebral fracture\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 05:00 PM\n 22 Gauge - 05:00 PM\n Multi Lumen - 07:07 PM\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: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2183-12-07 00:00:00.000", "description": "Intensivist Note", "row_id": 548171, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n .\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Acetaminophen, Amlodipine, Atorvastatin, Bisacodyl,Calcium Gluconate,\n Chlorhexidine Gluconate, Creon 10, Docusate, Famotidine, Gentamicin,\n HYDROmorphone (Dilaudid), Hydrochlorothiazide, Insulin, Influenza Virus\n Vaccine, Magnesium Sulfate, Metoprolol Tartrate, Midazolam,\n Pneumococcal Vac Polyvalent, Propofol, Senna, Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:45 PM\n OR RECEIVED - At 04:50 PM\n ARTERIAL LINE - START 05:00 PM\n MULTI LUMEN - START 07:07 PM\n Left subclavian\n URINE CULTURE - At 10:51 PM\n BLOOD CULTURED - At 02:51 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Gentamicin - 09:38 PM\n Infusions:\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 11:14 PM\n Hydromorphone (Dilaudid) - 12:13 AM\n Other medications:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.6\nC (99.6\n HR: 96 (68 - 106) bpm\n BP: 108/53(70) {74/48(62) - 146/69(94)} mmHg\n RR: 27 (19 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 7 (6 - 15) mmHg\n Total In:\n 8,204 mL\n 594 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,504 mL\n 594 mL\n Blood products:\n 700 mL\n Total out:\n 1,230 mL\n 198 mL\n Urine:\n 160 mL\n 178 mL\n NG:\n Stool:\n Drains:\n 55 mL\n 20 mL\n Balance:\n 6,974 mL\n 396 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): 490 (490 - 490) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.38/37/150/24/-2\n Ve: 15 L/min\n PaO2 / FiO2: 375\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, c-collar\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 Moves all extremities, Sedated\n Labs / Radiology\n 156 K/uL\n 10.7 g/dL\n 183 mg/dL\n 1.7 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 32 mg/dL\n 106 mEq/L\n 136 mEq/L\n 30.2 %\n 21.6 K/uL\n [image002.jpg]\n 04:22 AM\n 05:03 PM\n 05:15 PM\n 01:20 AM\n 01:26 AM\n 04:18 AM\n WBC\n 22.8\n 17.0\n 21.6\n Hct\n 43.9\n 30.7\n 30.2\n Plt\n 290\n 162\n 156\n Creatinine\n 1.3\n 1.6\n 1.7\n TCO2\n 24\n 23\n 23\n Glucose\n 142\n 202\n 183\n Other labs: PT / PTT / INR:13.5/24.3/1.2, Differential-Neuts:79.9 %,\n Lymph:10.3 %, Mono:9.2 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca:7.4\n mg/dL, Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), CERVICAL FRACTURE (WITHOUT SPINAL CORD INJURY),\n TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 dens fracture and C4\n fracture, s/p Operative fusion.\n 24 HOUR EVENTS:\n OR for C1/2 fusion, hypotensive requiring double pressors\n (peripherally)in OR\n weaned off levophed and propofol changed to midazolam, uop increased\n once levo off\n t 100.8--> am cxr, UA/cx sent, blood cx.\n Neurologic: Neuro checks Q: 1 hr, s/p C1-2 fusion, cont collar. cont\n neuro checks: moving all 4 ext when sedation decreased.\n Cardiovascular: hypotensive. diff dx includes septic (Tm 100.8 pod#1,\n no infectious source, +wbc 17), neurogenic (c-spine\n surgery/manipulation today, no tachycardia with hypotension) and\n hypovolemic (extensive blood loss in OR, now s/p 6L crystalloid, 2u\n prbcs, crit 30). CVL: 10. UOP:~20cc/hr. wean levo (currently off), goal\n map >60. follow uop, cvl, ci. follow crit.\n Pulmonary: intubated, ETT advanced 3cm s/p cxr. on cpap/ps, plan for\n extubation this am. rsbi: 74\n Gastrointestinal / Abdomen: no active issues. no NG/OG place overnight\n Nutrition: NPO\n Renal: Foley, Cr 1.1--> 1.6, no hx of RI, likely pre-renal intraop,\n follow uop and Cr. uop adequate since levophed d/ced\n Hematology: Hct 30, stable\n Endocrine: Insulin drip, cont insulin drip\n Infectious Disease: wbc elevated 17; fever post-op to 100.8: follow up\n UA/cx, blood cx, am cxr. continue vanc/gent per nsurg\n Lines / Tubes / Drains: L subclavian CVL (), PIV, foley, unable to\n place NGT overnight\n Wounds: R hand lac sutured, extensive surrounding bruising, small head\n lac\n Imaging:\n Fluids: then D51/2NS @ 80ml/hr, D10W 10 cc/hr\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Vertebral fracture\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 05:00 PM\n 22 Gauge - 05:00 PM\n Multi Lumen - 07:07 PM\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: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 35\n" }, { "category": "Respiratory ", "chartdate": "2183-12-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 548105, "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: Yes\n Procedure location: OR\n Reason: Fiber optically intubated secondary to neck collar.\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 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 claim of dyspnea.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Plan to remain intubated and mechanically ventilated\n secondary to facial edema. Pt. also received 6L fluid in OR. Plan to\n re-evaluate pt. in AM for possible extubation.\n" }, { "category": "Nursing", "chartdate": "2183-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548284, "text": "76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n Trauma, s/p MVC vs tree while hypoglycemic, type 2 dens fracture and\n teardrop fracture of C4 without deficits, s/p C1-2 fusion\n Assessment:\n Pt A&Ox3 c/o pain to neck relieved by percocet, tolerating RA\n and regular diet, titrating insulin gtt, neuro exam intact, posterior\n neck incision with JP and serosanginous drainage, right posterior hip\n graft site with sutures and dressing intact\n Action:\n Neuro checks changed to q4hours, BSq1 hour while on gtt\n Response:\n Pt continues with stable neuro exam\n Plan:\n Wean insulin gtt and continue to monitor neuro exam, ?transfer to floor\n if BS stable off gtt\n" }, { "category": "Nursing", "chartdate": "2183-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548260, "text": "76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n Trauma, s/p MVC vs tree while hypoglycemic, type 2 dens fracture and\n teardrop fracture of C4 without deficits, s/p C1-2 fusion\n Assessment:\n Pt A&Ox3 c/o pain to neck relieved by percocet, tolerating RA\n and regular diet\n Action:\n Neuro checks changed to q4hours, BSq1 hour\n Response:\n Pt continues with stable neuro exam\n Plan:\n Wean insulin gtt and continue to monitor neuro exam\n" }, { "category": "Physician ", "chartdate": "2183-12-08 00:00:00.000", "description": "Intensivist Note", "row_id": 548372, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n .\n ISSUES:\n 1) small head lac\n 2) R hand dorsal lac w/ exposed tendon, no deficit\n 3) C2 type II dens fx w/ post displacement, s/p fusion\n C2 lateral mass fx, into vert canal\n 4) C4 ant teardrop fx, widening of C4-5 intervertebral space, likely\n ligamentous injury\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Acetaminophen, Amlodipine, Atorvastatin, Bisacodyl, Calcium Gluconate,\n Creon, Docusate Sodium, Famotidine, Haloperidol, hydrochlorothiazide,\n Insulin, Influenza Virus Vaccine, Magnesium Sulfate, Metoprolol\n Tartrate, Oxycodone-Acetaminophen, piperacillin-Tazobactam Na,\n Pneumococcal Vac Polyvalent, Potassium Chloride, Senna, Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:32 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 06:11 AM\n Vancomycin - 08:00 PM\n Piperacillin - 02:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:00 AM\n Haloperidol (Haldol) - 09:35 AM\n Metoprolol - 04:38 AM\n Labetalol - 05:41 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: 37.2\nC (99\n T current: 37.1\nC (98.8\n HR: 84 (81 - 121) bpm\n BP: 143/74(91) {103/43(58) - 192/93(113)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 4 (0 - 6) mmHg\n Total In:\n 2,693 mL\n 320 mL\n PO:\n 90 mL\n Tube feeding:\n IV Fluid:\n 2,603 mL\n 320 mL\n Blood products:\n Total out:\n 1,991 mL\n 665 mL\n Urine:\n 1,871 mL\n 665 mL\n NG:\n Stool:\n Drains:\n 120 mL\n Balance:\n 702 mL\n -345 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 96%\n ABG: ///28/\n Physical Examination\n A&Ox3\n PERRL, EOMI\n Crackles\n Soft, nontenderm nondistended\n Follows commands with all four extremities\n RR\n Neck in C-collar\n Labs / Radiology\n 173 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 3.4 mEq/L\n 30 mg/dL\n 105 mEq/L\n 139 mEq/L\n 26.3 %\n 25.3 K/uL\n [image002.jpg]\n 04:22 AM\n 05:03 PM\n 05:15 PM\n 01:20 AM\n 01:26 AM\n 04:18 AM\n 01:57 AM\n WBC\n 22.8\n 17.0\n 21.6\n 25.3\n Hct\n 43.9\n 30.7\n 30.2\n 26.3\n Plt\n 290\n 162\n 156\n 173\n Creatinine\n 1.3\n 1.6\n 1.7\n 1.5\n TCO2\n 24\n 23\n 23\n Glucose\n 142\n 202\n 183\n 86\n Other labs: PT / PTT / INR:13.5/24.3/1.2, Differential-Neuts:79.9 %,\n Lymph:10.3 %, Mono:9.2 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca:8.1\n mg/dL, Mg:1.9 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: very low lung volumes\n CT C-spine: unstable type 2 dens fracture, acute teardrop\n fracture of C4, fracture involving the lateral mass of C1\n CT head: right frontal scalp superficial foreign bodies\n CT CAP: prelim - no injury to torso\n plain film hand : No fracture or foreign body\n plain film hand : pending\n MRI/MRA: no dissection, Known c2 and c4 fracture. No PLL injury.\n No definitive ALL tear, but suspicion high given the\n pre-vertebral soft tissue swelling\n CXR left-sided pleural effusion and some developing\n consolidation versus atelectasis in the left retrocardiac region since\n the prior study.\n CXR: infiltrate within the left retrocardiac region medially\n Microbiology: MRSA screen: pending\n UCx: negative\n Ucx: pending\n blood cx x2: pending\n sputum: OP flora\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), AIRWAY, INABILITY TO PROTECT\n (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), CERVICAL\n FRACTURE (WITHOUT SPINAL CORD INJURY), TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 dens fracture and C4\n fracture, s/p Operative fusion.\n Neurologic: Neuro checks Q: 1 hr\n change to q 4 as pt will be\n transferred to floor, s/p C1-2 fusion, cont collar; Pain: dilaudid prn,\n percocet PRN. D/C dilaudid.\n Cardiovascular: off pressors; restart amlodipine, HCTZ\n Pulmonary: extubated successfully, cont abx\n Gastrointestinal / Abdomen: no active issues. Start bowel regimen\n Nutrition: advance diet as tolerated\n Renal: Cr 1.1-> 1.7 -> 1.5. Renal insufficiency stabiblizing\n Hematology: Hct 30.2 -> 26.3. Stable anemia\n Endocrine: Insulin drip for hyperglycemia. F/ \ns recs to wean\n gtt to off.\n Infectious Disease: wbc elevated 17 ->21.6 ->26.3; follow cultures; abx\n changed from vanc/gent to vanc/zosyn due to Cr elevation.\n Lines / Tubes / Drains: L subclavian CVL (), PIV, foley\n Wounds: R hand lac, small head lac\n Imaging:\n Fluids: hold maintenance (signif volume up s/o OR, D10W at 10cc/hr w/\n insulin drip)\n Consults: Neuro surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 07:07 PM\n Prophylaxis:\n DVT: , start SQ heparin if o.k. with neurosurgery\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548232, "text": "Altered mental status (not Delirium)\n Assessment:\n Prior to extubation pt very agitated ad reaching for ETT. Post\n extubation he is confused, non verbal and agitated. Constantly pulling\n at lines, gown, sheets, bed etc. Had received versed during the night\n shift and maybe related to current MS. When more verbal described\n feeling very ansy. BG wnl.\n Action:\n Given small dose Haldol and close supervision for safety. Frequently\n reorientated.\n Response:\n Throughout day MS improved and current calm, A&Ox3. OOB to chair with\n little assist, eating soft diet and watching football. Does feel very\n tired and still nods off during conversations at times. Pain meds\n changed to Percocets for milder effect on mental status.\n Plan:\n Cont close monitoring and avoid further benzo use.\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548233, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt arousable this am, agitated and attempting to self extubate.\n Incosistntly FCs. +gag, +cough. Adeq sats and PaO2 on PS 5/5 and 40%.\n Lungs clear with small amts thick tan secretions.\n Action:\n Extubated at 0800. Placed on 40% open face tent.\n Response:\n Pt lungs clear to rhonchorous. Cough improved over shift as MS improved\n and able to now cough and expectorate sputum with yankuer. Using IS at\n times though still somewhat lethargic. O2 removed as it was further\n agitating pt, RA sats 95-97%.\n Plan:\n Cont pulmonary toileting and IS.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n Collar in place. MAEs with good strength. Sensation intact. Posterior\n incision with intial post-op dressing intact. Serosanginous drainage.\n JP with sanginous output in small amts. Bone donor site on R iliac\n crest with intact sutures. Serosang drainage and dressing changed this\n am. This evening pt given liquids and swallowed without signs of\n aspiration.\n Action:\n Collar maintained.\n Response:\n Compliant.\n Plan:\n Maintain collar. Aspiration precautions.\n Altered mental status (not Delirium)\n Assessment:\n Prior to extubation pt very agitated ad reaching for ETT. Post\n extubation he is confused, non verbal and agitated. Constantly pulling\n at lines, gown, sheets, bed etc. Had received versed during the night\n shift and maybe related to current MS. When more verbal described\n feeling very ansy. BG wnl.\n Action:\n Given small dose Haldol and close supervision for safety. Frequently\n reorientated.\n Response:\n Throughout day MS improved and current calm, A&Ox3. OOB to chair with\n little assist, eating soft diet and watching football. Does feel very\n tired and still nods off during conversations at times. Pain meds\n changed to Percocets for milder effect on mental status.\n Plan:\n Cont close monitoring and avoid further benzo use.\n" }, { "category": "Rehab Services", "chartdate": "2183-12-08 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 548379, "text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 76M unrestrained\n driver car versus tree. -ETOH GCS14. Pt was found to have multiple\n c-spine fractures including C2 type II dens fx w/ post displacement\n C2 lateral mass fx, into vert canal; C4 ant teardrop fx, widening of\n C4-5 intervertebral space, and likely ligamentous injury. Pt underwent\n Cervical fusion, C1-C2, with iliac crest bone graft . Pt developed\n some hypotension post op requiring pressors support, and was\n transferred to TSICU. His BP is now stable, and he is extubated.\n Past Medical / Surgical History: DM, HTN\n Medications: Amlodipine, Atorvastatin, Metoprolol, Vancomycin\n Radiology: Head CT -: CXR : There is a developing infiltrate\n within the left retrocardiac region medially : C-spine MRI: No evidence\n of posterior longitudinal ligamental injury. No definitive findings\n demonstrating an anterior longitudinal ligamental tear, but suspicion\n remains high given the avulsion injury\n Labs:\n 26.3\n 9.4\n 173\n 25.3\n [image002.jpg]\n Other labs:\n Activity Orders: C-collar at all times. OOB c A\n Social / Occupational History: Widowed, son lives in . Works at a\n restaurant\n Living Environment: Private home + stairs\n Prior Functional Status / Activity Level: I PTA, driving\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt A and O x with\n cues for date. Pt with poor short term memory able to recall 1 out of 3\n items after 5mins. Pt able to follow 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 91\n 137/61\n 98%Ra\n Rest\n /\n Sit\n 95\n 135/105\n 98%\n Activity\n /\n Stand\n /\n Recovery\n 97\n 115/65\n 99%RA\n Total distance walked:\n Minutes:\n Pulmonary Status: CTAB, strong nonproductive cough\n Integumentary / Vascular: C-collar in place, R iliac crest harvest site\n with dressing intact and area of errythemia surrounding it. foley, CVL,\n L LE posterior thigh ecchymosis, R scalp abrasion\n Sensory Integrity: Intact to LT t/o\n Pain / Limiting Symptoms: No reports of pain t/o evaluation\n Posture: increased thoracic kyphois\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n B LE > t.o\n Motor Function: Visual fields intact, no abnormal movement patterns\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 T\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: Pt was able to maintain sitting balance at EOB with B UE\n support; pt had posterior bias during dynamic sitting activities. Pt\n required min A to stand and take 2 small steps to chair with no gross\n LOB\n Education / Communication: Pt status discussed with RN, pt was seen\n with OT. Pt was educated on role of PT and d/c recommendations\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Transfers, Impaired\n Clinical impression / Prognosis: 76 yo m s/p MVC with resultant c-spine\n fx including type II dens fx s/p fusion. Pt presents with above\n impairments c/w fx. Pt is functioning below baseline limited by\n impaired cognition and mobility. Feel given pts living environment, and\n limited social supports along with current functional status, he would\n benefit from rehab upon d/c to optimize safety and function\n Goals\n Time frame: 1wk\n 1.\n I bed mobility\n 2.\n I transfers\n 3.\n I amb > 300'\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n f/u progress mobility, gait assessment, cont pt edu and d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 547609, "text": "76 YO M was driving and remembers feeling as if his blood sugar was\n low. He then remembers having the fire dept extract him from his car.\n Complained of neck pain upon arrival to ED. BS upon arrival was 46. CT\n scan shows type 2 dens fracture of the lateral mass of left C1.\n Teardrop fx of C4. No deficits noted, neuro exam intact. Tx to TSICU\n for Q1/hr neuro checks.\n Trauma, s/p with cervical fractures\n Assessment:\n Pt s/p MVC with type II Dens fx\n Action:\n Neuro assessments Q4/hr. J collar intact.\n Response:\n No neuro deficits noted. Pain well controlled, refusing pain meds at\n this time.\n Plan:\n Continue to monitor neuro assessments Q4/hr. Plan for surgery later in\n week (most likely Friday).\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 547610, "text": "76 YO M was driving and remembers feeling as if his blood sugar was\n low. He then remembers having the fire dept extract him from his car.\n Complained of neck pain upon arrival to ED. BS upon arrival was 46. CT\n scan shows type 2 dens fracture of the lateral mass of left C1.\n Teardrop fx of C4. No deficits noted, neuro exam intact. Tx to TSICU\n for Q1/hr neuro checks.\n Trauma, s/p with cervical fractures\n Assessment:\n Pt s/p MVC with type II Dens fx\n Action:\n Neuro assessments Q4/hr. J collar intact.\n Response:\n No neuro deficits noted. Pain well controlled, refusing pain meds at\n this time.\n Plan:\n Continue to monitor neuro assessments Q4/hr. Plan for surgery later in\n week (most likely Friday).\n ------ Protected Section ------\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Code status:\n Height:\n Admission weight:\n 100.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: whipple procedure \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:161\n D:77\n Temperature:\n 99\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,510 mL\n 24h total out:\n 2,230 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:22 AM\n Potassium:\n 4.0 mEq/L\n 04:22 AM\n Chloride:\n 102 mEq/L\n 04:22 AM\n CO2:\n 22 mEq/L\n 04:22 AM\n BUN:\n 24 mg/dL\n 04:22 AM\n Creatinine:\n 1.3 mg/dL\n 04:22 AM\n Glucose:\n 142 mg/dL\n 04:22 AM\n Hematocrit:\n 43.9 %\n 04:22 AM\n Finger Stick Glucose:\n 236\n 08:00 PM\n Valuables / Signature\n Patient valuables: glassess\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: cc6\n Date & time of Transfer:\n ------ Protected Section Addendum Entered By: , RN\n on: 23:46 ------\n" }, { "category": "Nursing", "chartdate": "2183-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548231, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt arousable this am, agitated and attempting to self extubate.\n Incosistntly FCs. +gag, +cough. Adeq sats and PaO2 on PS 5/5 and 40%.\n Lungs clear with small amts thick tan secretions.\n Action:\n Extubated at 0800. Placed on 40% open face tent.\n Response:\n Pt lungs clear to rhonchorous. Cough improved over shift as MS improved\n and able to now cough and expectorate sputum with yankuer. Using IS at\n times though still somewhat lethargic. O2 removed as it was further\n agitating pt, RA sats 95-97%.\n Plan:\n Cont pulmonary toileting and IS.\n Cervical fracture (without Spinal Cord Injury)\n Assessment:\n Collar in place. MAEs with good strength. Sensation intact. Posterior\n incision with intial post-op dressing intact. Serosanginous drainage.\n JP with sanginous output in small amts. Bone donor site on R iliac\n crest with intact sutures. Serosang drainage and dressing changed this\n am. This evening pt given liquids and swallowed without signs of\n aspiration.\n Action:\n Collar maintained.\n Response:\n Compliant.\n Plan:\n Maintain collar. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 547600, "text": "76 YO M was driving and remembers feeling as if his blood sugar was\n low. He then remembers having the fire dept extract him from his car.\n Complained of neck pain upon arrival to ED. BS upon arrival was 46. CT\n scan shows type 2 dens fracture of the lateral mass of left C1.\n Teardrop fx of C4. No deficits noted, neuro exam intact. Tx to TSICU\n for Q1/hr neuro checks.\n Trauma, s/p with cervical fractures\n Assessment:\n Pt s/p MVC with type II Dens fx\n Action:\n Neuro assessments Q4/hr. J collar intact.\n Response:\n No neuro deficits noted. Pain well controlled, refusing pain meds at\n this time.\n Plan:\n Continue to monitor neuro assessments Q4/hr. Plan for surgery later in\n week (most likely Friday).\n" }, { "category": "Physician ", "chartdate": "2183-12-08 00:00:00.000", "description": "Intensivist Note", "row_id": 548316, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n .\n ISSUES:\n 1) small head lac\n 2) R hand dorsal lac w/ exposed tendon, no deficit\n 3) C2 type II dens fx w/ post displacement, s/p fusion\n C2 lateral mass fx, into vert canal\n 4) C4 ant teardrop fx, widening of C4-5 intervertebral space, likely\n ligamentous injury\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Acetaminophen, Amlodipine, Atorvastatin, Bisacodyl, Calcium Gluconate,\n Creon, Docusate Sodium, Famotidine, Haloperidol, hydrochlorothiazide,\n Insulin, Influenza Virus Vaccine, Magnesium Sulfate, Metoprolol\n Tartrate, Oxycodone-Acetaminophen, piperacillin-Tazobactam Na,\n Pneumococcal Vac Polyvalent, Potassium Chloride, Senna, Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:32 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 06:11 AM\n Vancomycin - 08:00 PM\n Piperacillin - 02:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:00 AM\n Haloperidol (Haldol) - 09:35 AM\n Metoprolol - 04:38 AM\n Labetalol - 05:41 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: 37.2\nC (99\n T current: 37.1\nC (98.8\n HR: 84 (81 - 121) bpm\n BP: 143/74(91) {103/43(58) - 192/93(113)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 4 (0 - 6) mmHg\n Total In:\n 2,693 mL\n 320 mL\n PO:\n 90 mL\n Tube feeding:\n IV Fluid:\n 2,603 mL\n 320 mL\n Blood products:\n Total out:\n 1,991 mL\n 665 mL\n Urine:\n 1,871 mL\n 665 mL\n NG:\n Stool:\n Drains:\n 120 mL\n Balance:\n 702 mL\n -345 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 96%\n ABG: ///28/\n Physical Examination\n A&Ox3\n PERRL, EOMI\n Crackles\n Soft, nontenderm nondistended\n Follows commands with all four extremities\n RR\n Neck in C-collar\n Labs / Radiology\n 173 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 3.4 mEq/L\n 30 mg/dL\n 105 mEq/L\n 139 mEq/L\n 26.3 %\n 25.3 K/uL\n [image002.jpg]\n 04:22 AM\n 05:03 PM\n 05:15 PM\n 01:20 AM\n 01:26 AM\n 04:18 AM\n 01:57 AM\n WBC\n 22.8\n 17.0\n 21.6\n 25.3\n Hct\n 43.9\n 30.7\n 30.2\n 26.3\n Plt\n 290\n 162\n 156\n 173\n Creatinine\n 1.3\n 1.6\n 1.7\n 1.5\n TCO2\n 24\n 23\n 23\n Glucose\n 142\n 202\n 183\n 86\n Other labs: PT / PTT / INR:13.5/24.3/1.2, Differential-Neuts:79.9 %,\n Lymph:10.3 %, Mono:9.2 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca:8.1\n mg/dL, Mg:1.9 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: very low lung volumes\n CT C-spine: unstable type 2 dens fracture, acute teardrop\n fracture of C4, fracture involving the lateral mass of C1\n CT head: right frontal scalp superficial foreign bodies\n CT CAP: prelim - no injury to torso\n plain film hand : No fracture or foreign body\n plain film hand : pending\n MRI/MRA: no dissection, Known c2 and c4 fracture. No PLL injury.\n No definitive ALL tear, but suspicion high given the\n pre-vertebral soft tissue swelling\n CXR left-sided pleural effusion and some developing\n consolidation versus atelectasis in the left retrocardiac region since\n the prior study.\n CXR: infiltrate within the left retrocardiac region medially\n Microbiology: MRSA screen: pending\n UCx: negative\n Ucx: pending\n blood cx x2: pending\n sputum: OP flora\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), AIRWAY, INABILITY TO PROTECT\n (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), CERVICAL\n FRACTURE (WITHOUT SPINAL CORD INJURY), TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 dens fracture and C4\n fracture, s/p Operative fusion.\n Neurologic: Neuro checks Q: 1 hr, s/p C1-2 fusion, cont collar; Pain:\n dilaudid prn, percocet PRN\n Cardiovascular: off pressors; restart amlodipine, HCTZ\n Pulmonary: extubated successfully, possible developing infiltrate\n within the left retrocardiac region medially, cont abx\n Gastrointestinal / Abdomen: no active issues\n Nutrition: advance diet as tolerated\n Renal: Cr 1.1-> 1.7 -> 1.5\n Hematology: Hct 30.2 -> 26.3\n Endocrine: Insulin drip\n Infectious Disease: wbc elevated 17 ->21.6 ->26.3; follow cultures; abx\n changed from vanc/gent to vanc/zosyn due to Cr elevation\n Lines / Tubes / Drains: L subclavian CVL (), PIV, foley\n Wounds: R hand lac, small head lac\n Imaging:\n Fluids: hold maintenance (signif volume up s/o OR, D10W at 10cc/hr w/\n insulin drip)\n Consults: Neuro surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 07:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2183-12-08 00:00:00.000", "description": "Intensivist Note", "row_id": 548304, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervial spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo.\n .\n ISSUES:\n 1) small head lac\n 2) R hand dorsal lac w/ exposed tendon, no deficit\n 3) C2 type II dens fx w/ post displacement, s/p fusion\n C2 lateral mass fx, into vert canal\n 4) C4 ant teardrop fx, widening of C4-5 intervertebral space, likely\n ligamentous injury\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Acetaminophen, Amlodipine, Atorvastatin, Bisacodyl, Calcium Gluconate,\n Creon, Docusate Sodium, Famotidine, Haloperidol, hydrochlorothiazide,\n Insulin, Influenza Virus Vaccine, Magnesium Sulfate, Metoprolol\n Tartrate, Oxycodone-Acetaminophen, piperacillin-Tazobactam Na,\n Pneumococcal Vac Polyvalent, Potassium Chloride, Senna, Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:32 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 06:11 AM\n Vancomycin - 08:00 PM\n Piperacillin - 02:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 09:00 AM\n Haloperidol (Haldol) - 09:35 AM\n Metoprolol - 04:38 AM\n Labetalol - 05:41 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: 37.2\nC (99\n T current: 37.1\nC (98.8\n HR: 84 (81 - 121) bpm\n BP: 143/74(91) {103/43(58) - 192/93(113)} mmHg\n RR: 26 (18 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 4 (0 - 6) mmHg\n Total In:\n 2,693 mL\n 320 mL\n PO:\n 90 mL\n Tube feeding:\n IV Fluid:\n 2,603 mL\n 320 mL\n Blood products:\n Total out:\n 1,991 mL\n 665 mL\n Urine:\n 1,871 mL\n 665 mL\n NG:\n Stool:\n Drains:\n 120 mL\n Balance:\n 702 mL\n -345 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n FiO2: 50%\n SPO2: 96%\n ABG: ///28/\n Physical Examination\n Labs / Radiology\n 173 K/uL\n 9.4 g/dL\n 86 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 3.4 mEq/L\n 30 mg/dL\n 105 mEq/L\n 139 mEq/L\n 26.3 %\n 25.3 K/uL\n [image002.jpg]\n 04:22 AM\n 05:03 PM\n 05:15 PM\n 01:20 AM\n 01:26 AM\n 04:18 AM\n 01:57 AM\n WBC\n 22.8\n 17.0\n 21.6\n 25.3\n Hct\n 43.9\n 30.7\n 30.2\n 26.3\n Plt\n 290\n 162\n 156\n 173\n Creatinine\n 1.3\n 1.6\n 1.7\n 1.5\n TCO2\n 24\n 23\n 23\n Glucose\n 142\n 202\n 183\n 86\n Other labs: PT / PTT / INR:13.5/24.3/1.2, Differential-Neuts:79.9 %,\n Lymph:10.3 %, Mono:9.2 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca:8.1\n mg/dL, Mg:1.9 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: very low lung volumes\n CT C-spine: unstable type 2 dens fracture, acute teardrop\n fracture of C4, fracture involving the lateral mass of C1\n CT head: right frontal scalp superficial foreign bodies\n CT CAP: prelim - no injury to torso\n plain film hand : No fracture or foreign body\n plain film hand : pending\n MRI/MRA: no dissection, Known c2 and c4 fracture. No PLL injury.\n No definitive ALL tear, but suspicion high given the\n pre-vertebral soft tissue swelling\n CXR left-sided pleural effusion and some developing\n consolidation versus atelectasis in the left retrocardiac region since\n the prior study.\n CXR: infiltrate within the left retrocardiac region medially\n Microbiology: MRSA screen: pending\n UCx: negative\n Ucx: pending\n blood cx x2: pending\n sputum: OP flora\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), AIRWAY, INABILITY TO PROTECT\n (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), CERVICAL\n FRACTURE (WITHOUT SPINAL CORD INJURY), TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 dens fracture and C4\n fracture, s/p Operative fusion.\n Neurologic: Neuro checks Q: 1 hr, s/p C1-2 fusion, cont collar; Pain:\n dilaudid prn, percocet PRN\n Cardiovascular: off pressors; restart amlodipine, HCTZ\n Pulmonary: extubated successfully, possible developing infiltrate\n within the left retrocardiac region medially, cont abx\n Gastrointestinal / Abdomen: no active issues\n Nutrition: advance diet as tolerated\n Renal: Cr 1.1-> 1.7 -> 1.5\n Hematology: Hct 30.2 -> 26.3\n Endocrine: Insulin drip\n Infectious Disease: wbc elevated 17 ->21.6 ->26.3; follow cultures; abx\n changed from vanc/gent to vanc/zosyn due to Cr elevation\n Lines / Tubes / Drains: L subclavian CVL (), PIV, foley\n Wounds: R hand lac, small head lac\n Imaging:\n Fluids: hold maintenance (signif volume up s/o OR, D10W at 10cc/hr w/\n insulin drip)\n Consults: Neuro surgery\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 07:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2183-12-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 548223, "text": "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: Blood Tinged / Thick\n Sputum source/amount: Nasotrachial Suction / Copious\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt. received on PSV 5/5. Positive cough leak test. Pt\n extubated to cool aerosol without any incident.\n Assessment of breathing comfort: No claim of dyspnea.\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 547591, "text": "Trauma, s/p\n Assessment:\n No motor or sensory deficit noted on Q1h neuro checks. Denies pain. CSM\n intact.\n Action:\n MRI done to evaluated fractures.\n Response:\n Dr visited pt and family this afternoon and reviewed findings and\n POC.\n Plan:\n Surgery planned for sometime in next few days.\n Pt has h/o HTN. Unable to report baseline BP. MD aware in MRI BP\n 200s/110s.Treated with lopressor IV with mild effects. In unit max BP\n 180s/100. On standing lopressor and norvasc home dose. HO aware SBP\n 160-170s. Will tolerate higher bp per resident.\n" }, { "category": "Nursing", "chartdate": "2183-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 548292, "text": "76M unrestrained driver car versus tree. -ETOH GCS14. BS 49, D50 given\n on field. Multiple c-spine fractures with no other injuries, now s/p\n cervical spine fusion. In the OR pt originally hypertensive but\n subsequently hypotensive requiring neo and levo. Transferred to TSICU\n post op for monitoring\n Trauma, s/p MVC vs. tree while hypoglycemic, type 2 dens fracture and\n teardrop fracture of C4 without deficits, s/p C1-2 fusion\n Assessment:\n Pt A&Ox3 c/o pain to neck relieved by percocet, tolerating RA\n and regular diet, titrating insulin gtt, neuro exam intact, posterior\n neck incision with JP and serosanginous drainage, right posterior hip\n graft site with sutures and dressing intact\n Action:\n Neuro checks changed to q4hours, BSq1 hour while on gtt\n Response:\n Pt continues with stable neuro exam\n Plan:\n Wean insulin gtt and continue to monitor neuro exam, ?transfer to floor\n if BS stable off gtt\n ** pt slightly hypertensive throughout shift and treated with PRN\n Lopressor and labetolol, due for am cardiac meds this morning, ICU\n resident aware of hypertension, will re-assess***\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 547590, "text": "Trauma, s/p\n Assessment:\n No motor or sensory deficit noted on Q1h neuro checks. Denies pain. CSM\n intact.\n Action:\n MRI done to evaluated fractures.\n Response:\n Dr visited pt and family this afternoon and reviewed findings and\n POC.\n Plan:\n Surgery planned for sometime in next few days.\n" }, { "category": "Physician ", "chartdate": "2183-12-03 00:00:00.000", "description": "Intensivist Note", "row_id": 547505, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree, likely head vs windshield w/\n hyperextension +LOC - ETOH GCS14. BS 49, D50 given on field. Multiple\n c-spine fractures with no other injuries.\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Famotidine, Heparin, Insulin, Metoprolol, Morphine\n 24 Hour Events:\n hand lac sutured, Q1 neuro checks\n Post operative day:\n none\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:06 AM\n Heparin Sodium (Prophylaxis) - 05:06 AM\n Other medications:\n Flowsheet Data as of 09:23 AM\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: 77 (77 - 105) bpm\n BP: 136/81(93) {136/79(93) - 182/93(111)} mmHg\n RR: 15 (13 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 972 mL\n PO:\n Tube feeding:\n IV Fluid:\n 472 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///22/\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: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), sutured head laceration\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, No(t) Noxious stimuli),\n Moves all extremities\n Labs / Radiology\n 290 K/uL\n 15.1 g/dL\n 142 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 22.8 K/uL\n [image002.jpg]\n 04:22 AM\n WBC\n 22.8\n Hct\n 43.9\n Plt\n 290\n Creatinine\n 1.3\n Glucose\n 142\n Other labs: Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 type 2 dens fracture and C4\n fracture.\n Neurologic: Neuro checks Q: 1 hr, cont collar. MRI/MRA c-spine. Off\n logroll.\n Cardiovascular: HTN->lopressor IV\n Pulmonary: no issues\n Gastrointestinal / Abdomen: no issues\n Nutrition: NPO, no issues\n Renal: Cr 1.3, 1L w/ HCO3\n Hematology: Hct and INR stable\n Endocrine: RISS, no issues\n Infectious Disease: wbc elevated 14->23\n Lines / Tubes / Drains: Foley, PIV\n Wounds:\n Imaging: MRI c-spine today\n Fluids: 1L HCO3\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Vertebral fracture, Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2183-12-03 00:00:00.000", "description": "Intensivist Note", "row_id": 547503, "text": "TSICU\n HPI:\n 76M Unrestrained driver car versus tree, likely head vs windshield w/\n hyperextension +LOC - ETOH GCS14. BS 49, D50 given on field. Multiple\n c-spine fractures with no other injuries.\n Chief complaint:\n neck pain\n PMHx:\n DM2, HTN, ^lipid, whipple for \"black pancreas\", left leg excision of\n benign mass\n Current medications:\n Famotidine, Heparin, Insulin, Metoprolol, Morphine\n 24 Hour Events:\n hand lac sutured, Q1 neuro checks\n Post operative day:\n none\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:06 AM\n Heparin Sodium (Prophylaxis) - 05:06 AM\n Other medications:\n Flowsheet Data as of 09:23 AM\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: 77 (77 - 105) bpm\n BP: 136/81(93) {136/79(93) - 182/93(111)} mmHg\n RR: 15 (13 - 20) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 972 mL\n PO:\n Tube feeding:\n IV Fluid:\n 472 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 192 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///22/\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: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact), sutured head laceration\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, No(t) Noxious stimuli),\n Moves all extremities\n Labs / Radiology\n 290 K/uL\n 15.1 g/dL\n 142 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 22.8 K/uL\n [image002.jpg]\n 04:22 AM\n WBC\n 22.8\n Hct\n 43.9\n Plt\n 290\n Creatinine\n 1.3\n Glucose\n 142\n Other labs: Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n TRAUMA, S/P\n Assessment and Plan: 76yM s/p MVA with C2 type 2 dens fracture and C4\n fracture.\n Neurologic: Neuro checks Q: 1 hr, cont collar. MRI/MRA c-spine. Off\n logroll.\n Cardiovascular: HTN->lopressor IV\n Pulmonary: no issues\n Gastrointestinal / Abdomen: no issues\n Nutrition: NPO, no issues\n Renal: Cr 1.3, 1L w/ HCO3\n Hematology: Hct and INR stable\n Endocrine: RISS, no issues\n Infectious Disease: wbc elevated 14->23\n Lines / Tubes / Drains: Foley, PIV\n Wounds:\n Imaging: MRI c-spine today\n Fluids: 1L HCO3\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Vertebral fracture, Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Comments: npo\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 547467, "text": "76 YO M was driving and remembers feeling as if his blood sugar was\n low. He then remembers having the fire dept extract him from his car.\n Complained of neck pain upon arrival to ED. BS upon arrival was 46. CT\n scan shows type 2 dens fracture of the lateral mass of left C1.\n Teardrop fx of C4. No deficits noted, neuro exam intact. Tx to TSICU\n for Q1/hr neuro checks.\n Trauma, s/p with cervical fractures\n Assessment:\n Pt s/p MVC with type II Dens fx\n Action:\n Neuro assessments Q1/hr. J collar intact. Logroll precautions\n maintained.\n Response:\n No neuro deficits noted. Pain well controlled, refusing pain meds at\n this time.\n Plan:\n Continue to monitor neuro assessments Q/hr. MRA/MRI of c-spine today. ?\n need for surgical intervention.\n" }, { "category": "Nursing", "chartdate": "2183-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 547478, "text": "76 YO M was driving and remembers feeling as if his blood sugar was\n low. He then remembers having the fire dept extract him from his car.\n Complained of neck pain upon arrival to ED. BS upon arrival was 46. CT\n scan shows type 2 dens fracture of the lateral mass of left C1.\n Teardrop fx of C4. No deficits noted, neuro exam intact. Tx to TSICU\n for Q1/hr neuro checks.\n Trauma, s/p with cervical fractures\n Assessment:\n Pt s/p MVC with type II Dens fx\n Action:\n Neuro assessments Q1/hr. J collar intact. Logroll precautions\n maintained.\n Response:\n No neuro deficits noted. Pain well controlled, refusing pain meds at\n this time.\n Plan:\n Continue to monitor neuro assessments Q/hr. MRA/MRI of c-spine today. ?\n need for surgical intervention.\n" }, { "category": "Radiology", "chartdate": "2183-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1051554, "text": " 2:35 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for improvement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent intubation being treated for aspiration pneumonia,\n last CXR showed infiltrate within the left retrocardiac region medially\n REASON FOR THIS EXAMINATION:\n Assess for improvement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 3:25 PM\n Left lower lobe infiltrates cleared up. No new abnormalities. The patient\n has been extubated during interval.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Recent intubation, now being treated for aspiration pneumonia.\n Last preceding chest x-ray demonstrated infiltrate within the left\n retrocardiac region medially. Assess improvement.\n\n FINDINGS: AP and lateral chest views have been obtained with patient in\n sitting semi-upright position. Available for comparison is a preceding AP\n single-view chest examination of . Comparison of the frontal\n views demonstrates that the previously suspected local densities in\n retrocardiac position have clearly improved. There remains a thin plate\n atelectasis, but no conclusive evidence of any true parenchymal infiltrate.\n Heart size remains unchanged and within normal limits. Previously described\n left subclavian approach central venous line in unchanged position. No\n evidence of pneumothorax. The lateral view which was obtained with patient in\n sitting semi-upright position demonstrates that the lung fields are clear,\n however, there exists a very mild degree of blunting of the posterior pleural\n sinuses consistent with small pleural effusions.\n\n IMPRESSION: Left lower lobe atelectasis - infiltrate has cleared up and\n improved. No new abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1051555, "text": ", W. NSURG FA11 2:35 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for improvement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent intubation being treated for aspiration pneumonia,\n last CXR showed infiltrate within the left retrocardiac region medially\n REASON FOR THIS EXAMINATION:\n Assess for improvement\n ______________________________________________________________________________\n PFI REPORT\n Left lower lobe infiltrates cleared up. No new abnormalities. The patient\n has been extubated during interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1051034, "text": " 5:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with post op fever\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 76-year-old male with postop fever.\n\n FINDINGS: Comparison is made to prior study from .\n\n The tip of the endotracheal tube is again high, 8.5 cm above the carina, and\n could be advanced approximately 2 to 3 cm for optimal placement. The left-\n sided central venous catheter tip is unchanged. There is a developing\n infiltrate within the left retrocardiac region medially. There is no overt\n pulmonary edema or large pleural effusions.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-06 00:00:00.000", "description": "SPINAL FLUORO WITH RADIOLOGIST", "row_id": 1050978, "text": " 4:47 PM\n SPINAL FLUORO WITH RADIOLOGIST Clip # \n Reason: FIXATION IN THE OR\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n\n 31 seconds of fluoro performed in the O.R. without a radiologist present. No\n films submitted to PACS.\n\n" }, { "category": "Radiology", "chartdate": "2183-12-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1050988, "text": " 6:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with L subclavian\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n WET READ: CXWc SAT 8:54 PM\n The patient is rotated and lung volumes are low. The left SCC likely\n terminates at the SVC-RA junction. The ETT terminates 10cm from the carina\n and can be advanced for standard positioning. Atelectasis at the left lung\n base.\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: AP chest, .\n\n HISTORY: 76-year-old man with left subclavian central line placement.\n\n FINDINGS: Comparison is made to prior study from .\n\n The left-sided central venous catheter has the distal tip in the mid to distal\n SVC appropriately sited. No pneumothoraces are seen. Endotracheal tube tip\n is high, could be advanced several centimeters for more optimal placement. The\n tip is 11 cm from the carina, could be advanced at least 4-5 cm. Surgical\n clips are seen within the right lower neck. There is a left-sided pleural\n effusion and some developing consolidation versus atelectasis in the left\n retrocardiac region since the prior study.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1050283, "text": " 8:06 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: assess c spine injury, cord injury\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with C2 fx, C4 fx, suspected lig injury\n REASON FOR THIS EXAMINATION:\n assess c spine injury, cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa WED 7:28 PM\n 1. Known c2 and c4 fracture.\n 2. No PLL injury. No definitive ALL tear, but suspicion remains high given the\n pre-vertebral soft tissue swelling.\n 3. No cord compression, contusion or intraspinal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with odontoid fracture and C4 fracture, suspected\n ligamental injury.\n\n TECHNIQUE: Sagittal short TR, short TE spin-echo, long TR, long TE, fast\n spin-echo, and STIR images were obtained. Axial gradient-echo scans and long\n TR and long TE fast spin-echo images were performed. No contrast was\n administered.\n\n COMPARISON: CT cervical spine without contrast on .\n\n FINDINGS:\n\n Again noted is the odontoid fracture with 4-mm posterior displacement. At\n C4/C5, there is a small linear T2 hyperintense signal in the intervertebral\n disc space, with evidence of a small \"tear-drop\" deformity in the anterior-\n inferior endplate of C4, corresponding to the prior CT finding of a small\n avulsion injury. There is prevertebral soft tissue swelling. The vertebral\n bodies of C5 and C6 are fused.\n\n There is no posterior longitudinal ligamental injury. There are no definitive\n evidence of anterior longitudinal ligamental tear, but suspicion remains high\n in the setting of the prevertebral tissue swelling. The prevertebral tissue\n swelling could alternatively be explained by the odontoid fracture. There is\n no encroachment of the spinal canal. There is no spinal stenosis. There is no\n intraspinal hematoma or cord contusion.\n\n IMPRESSION:\n\n 1. C2 and C4 fractures as described above.\n\n 2. No evidence of posterior longitudinal ligamental injury. No definitive\n findings demonstrating an anterior longitudinal ligamental tear, but suspicion\n remains high given the avulsion injury.\n\n 3. Fusion of C5 and C6.\n (Over)\n\n 8:06 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: assess c spine injury, cord injury\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. No spinal canal encroaching or intraspinal hematoma or cord contusion.\n\n The findings of this exam have been communicated to the primary team, Dr.\n at 12 p.m. on the day of study.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1050284, "text": ", M. TSICU 8:06 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: assess c spine injury, cord injury\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with C2 fx, C4 fx, suspected lig injury\n REASON FOR THIS EXAMINATION:\n assess c spine injury, cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Known c2 and c4 fracture.\n 2. No PLL injury. No definitive ALL tear, but suspicion remains high given the\n pre-vertebral soft tissue swelling.\n 3. No cord compression, contusion or intraspinal hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "MRA NECK W&W/O CONTRAST", "row_id": 1050285, "text": " 8:06 AM\n MRA NECK W&W/O CONTRAST Clip # \n Reason: assess for L vert a dissection\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with C2 fx, C4 fx, suspected lig injury\n REASON FOR THIS EXAMINATION:\n assess for L vert a dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ENYa WED 7:14 PM\n left vertebral artery patent without definitive evidence of intramural blood.\n However, evolving dissection may not be visualized in an acute setting by MRA.\n If clinical suspicion remains high, recommend repeating study in a few days.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with known odontoid fracture and C4 fracture,\n suspect ligamental injury, assess for potential left vertebral artery\n dissection.\n\n TECHNIQUE: Two-dimensional time-of-flight MRA was performed. Coronal VIBE\n imaging was performed during infusion of intravenous contrast. Rotational\n reformatted images were prepared.\n\n COMPARISON: CT spine without contrast on .\n\n FINDINGS:\n The bony fractures at C2 and C4 are again evidenced, please refer to the MR\n cervical spine for full assessment. The carotid and vertebral arteries are\n visualized from their origins to their intracranial courses. There is no\n evidence of stenosis or occlusion. Specifically, the left vertebral artery is\n patent, without evidence of intramural clot on the current exam. However,\n given the acute nature, intramural hemorrhage may not yet be hyperintense on\n MR. If a dissection remains a clinical concern, then a follow up MR after\n several days may increase sensitivity for such hemorrhage. This sort of\n dissection will be essentially invisible on CT or CTA at any time, and\n these studies would not be useful for this diagnosis.\n\n The distal cervical internal carotid arteries measure 4 mm in diameter on the\n right and 4 mm in diameter on the left.\n\n IMPRESSION:\n Left vertebral artery patent without evidence of intramural clot; however,\n given the acute nature, intramural hemorrhage may not be hyperintense on MR at\n this point. If there is high clinical concern for a small dissection,\n a repeat MR in a few days may increase sensitivity.\n\n The findings of this study have been communicated to the ordering team, Dr.\n at 12:00 p.m. on the day of the study.\n\n\n (Over)\n\n 8:06 AM\n MRA NECK W&W/O CONTRAST Clip # \n Reason: assess for L vert a dissection\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "MRA NECK W&W/O CONTRAST", "row_id": 1050286, "text": ", M. TSICU 8:06 AM\n MRA NECK W&W/O CONTRAST Clip # \n Reason: assess for L vert a dissection\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with C2 fx, C4 fx, suspected lig injury\n REASON FOR THIS EXAMINATION:\n assess for L vert a dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n left vertebral artery patent without definitive evidence of intramural blood.\n However, evolving dissection may not be visualized in an acute setting by MRA.\n If clinical suspicion remains high, recommend repeating study in a few days.\n\n" }, { "category": "Radiology", "chartdate": "2183-12-04 00:00:00.000", "description": "CHEST (PRE-OP AP ONLY)", "row_id": 1050592, "text": " 3:11 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n pt is pre-op\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:07 PM\n No acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n PREOP CHEST X-RAY\n\n HISTORY: 76-year-old male, preop for cervical surgery on .\n\n COMPARISONS: .\n\n AP CHEST: Allowing for the AP technique, the heart is probably normal in\n size. The mediastinal and hilar contours are normal. The lungs are clear.\n Blunting of the left costophrenic angle is evident. There is no pneumothorax\n or pleural effusion.\n\n A single clip projects over the medial aspect of the left upper abdomen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "RP HAND (AP, LAT & OBLIQUE) RIGHT PORT", "row_id": 1050246, "text": " 1:45 AM\n HAND (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: ? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right hand laceration after MVC\n REASON FOR THIS EXAMINATION:\n ? fx\n ______________________________________________________________________________\n FINAL REPORT\n AP, lateral, and oblique radiographs of the right hand.\n\n INDICATION: Pain and laceration after motor vehicle collision.\n COMPARISONS: None.\n\n FINDINGS: No soft tissue laceration is appreciated. However, bandage\n material overlies the dorsum of the hand. No radiopaque foreign bodies. No\n evidence of acute fracture or traumatic malalignment. Severe degenerative\n changes are noted involving the second through fifth digit DIP and PIP joints.\n First CMC joint demonstrates degenerative changes with joint space narrowing,\n subchondral sclerosis.\n\n IMPRESSION: No fracture or opaque foreign body. Severe osteoarthritis.\n\n" }, { "category": "Radiology", "chartdate": "2183-12-04 00:00:00.000", "description": "CHEST (PRE-OP AP ONLY)", "row_id": 1050593, "text": ", W. NSURG CC6A 3:11 PM\n CHEST (PRE-OP AP ONLY) Clip # \n Reason: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n pt is pre-op\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "LP HAND (AP, LAT & OBLIQUE) LEFT PORT", "row_id": 1050255, "text": " 3:22 AM\n HAND (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: ? L third finger fx?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with large hematoma L third finger s/p MVC\n REASON FOR THIS EXAMINATION:\n ? L third finger fx?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVA. Third finger hematoma and pain.\n\n Three views of the left hand show prominent osteoarthritis with joint space\n narrowing and osteophytes in the PIP and DIP joints of the second-fifth\n fingers and the first CMC joint. There is equivocal joint space narrowing in\n the second through fifth MP joints, but no erosive changes and normal bone\n mineral. Incidental oximeter on the index finger. No fracture identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1050242, "text": " 12:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with mvc\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi WED 1:20 AM\n No acute hemorrage. Clinically correlate for superficial foreign bodies in the\n right frontal soft tissues.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: Motor vehicle collision.\n\n COMPARISONS: None available.\n\n FINDINGS: Several small high density objects are noted within the soft\n tissues overlying the right frontal bone. Please correlate for foreign\n bodies. There has been a left lens replacement. The visualized paranasal\n sinuses and mastoid air cells are clear. No evidence of acute fracture is\n identified.\n\n Mild periventricular hypoattenuation is most consistent with chronic\n microvascular ischemia. There is no evidence of infarction, hemorrhage, mass\n lesion, shift of normally midline structures, or hydrocephalus. The major\n basilar cisterns are preserved. There is minor calcification of the cavernous\n carotid arteries.\n\n IMPRESSION:\n\n 1. No evidence of hemorrhage or mass effect.\n\n 2. Please clinically correlate right frontal scalp for superficial foreign\n bodies.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1050243, "text": " 12:38 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with mvc chest contusion\n REASON FOR THIS EXAMINATION:\n trauma?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi WED 1:37 AM\n Type 2 dens fracture with fracture of the lateral mass of left C1. Teardrop\n fracture of c4 with widening of the C4-5 interspace and probable rupture of\n the ALL. Recommend MRI and MRA of the cervical spine as discussed with\n trauma.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT cervical spine without contrast and reconstructions.\n\n INDICATION: High speed motor vehicle collision, pain.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT axially acquired images were obtained of the cervical spine\n without contrast. Multiplanar reformatted images were obtained and reviewed.\n\n FINDINGS: There is an acute unstable fracture of the dens (type 2) with 4 mm\n posterior retropulsion of the cranial aspect of the dens. The atlantodental\n joint remains intact. There is an acute teardrop fracture involving the\n anterior inferior corner of C4 with widening of the intervertebral body space\n at C4-C5. There is fusion of C5 and C6. There is presumed rupture of the\n anterior longitudinal ligament at the C4-C5 level. There is prevertebral soft\n tissue hemorrhage. The airway remains patent. There are degenerative changes\n involving the facet joints with autofusion of the right C3-C4 facet joints and\n severe joint space narrowing and subchondral sclerosis involving the bilateral\n facet joints from C2 through C4. There is calcification of the nuchal\n ligament incidentally noted.\n\n The thyroid gland appears unremarkable. No traumatic pneumothorax detected\n within the visualized lung apices.\n\n There is an acute minimally displaced fracture involving the lateral mass of\n C1 on the left extending into the left neural foramen.\n\n IMPRESSION:\n\n 1. Unstable type 2 dens fracture with 4 mm retropulsion of the cranial\n fracture fragment. Acute teardrop fracture of C4 with intervertebral body\n disc space widening anteriorly at the C4-C5 level with presumed anterior\n longitudinal ligament rupture. MRI of the cervical spine is recommended for\n further evaluation.\n\n 2. Acute minimally displaced fracture involving the lateral mass of C1 on the\n (Over)\n\n 12:38 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: MVC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left involving the transverse foramen. MRI may be helpful to evaluate\n possible injury to the vertebral artery.\n\n Neurosurgical consult recommended as discussed with the trauma team.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1050244, "text": " 12:39 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MVC\n Field of view: 41 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with mvc chest contusion\n REASON FOR THIS EXAMINATION:\n intrathoracic trauma?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi WED 1:35 AM\n no acute injury to the torso`\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT torso with contrast and reconstructions.\n\n INDICATION: Trauma, high speed motor vehicle collision with chest contusion.\n\n COMPARISONS: None available.\n\n TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet\n to the symphysis after the uneventful intravenous administration of contrast\n material. Multiplanar reformatted images were obtained and reviewed.\n\n CONTRAST: 130 cc Optiray 350 contrast material.\n\n CT CHEST WITH CONTRAST: No dissection flap is present within the thoracic\n aorta. There is coarse three-vessel coronary artery calcifications. The\n heart is intact without pericardial effusion. The major airways are patent\n down to the subsegmental level. No axillary, mediastinal, or hilar adenopathy\n is detected.\n\n Evaluation of the lung parenchyma is limited given motion artifact. There are\n bibasilar atelectasis and hypoventilatory changes within the dependent portion\n of the lungs. No evidence of pulmonary contusion or pneumothorax is present.\n\n CT ABDOMEN WITH CONTRAST: No mass lesions are detected within the liver.\n There is pneumobilia consistent with known Whipple procedure. There is no\n intra- or extra-hepatic biliary ductal dilatation. The pancreas is not\n visualized consistent with pancreatectomy. Several soft tissue nodules are\n noted within the left upper quadrant likely representing splenules. No free\n air or free fluid is identified within the abdomen. There is no evidence of\n bowel obstruction or bowel wall thickening to suggest acute bowel injury. The\n kidneys enhance and excrete symmetrically without hydronephrosis. A 1.2 cm\n cyst is noted within the interpolar region of the left kidney.\n\n CT PELVIS WITH CONTRAST: There is a moderate-sized left inguinal hernia with\n interposed colon within. The bladder is moderately distended with fluid\n without evidence of leak or focal lesion. Prostatic enlargement noted with\n the prostate measuring 4.8 cm in greatest transverse dimension. The rectum\n and sigmoid colon appear unremarkable. There is no free pelvic fluid\n (Over)\n\n 12:39 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: MVC\n Field of view: 41 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n identified.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.\n There is no evidence of acute fracture. Degenerative changes are noted within\n the lower lumbar spine with facet joint hypertrophy. There is intervertebral\n body disc space narrowing most notable at the L5-S1 level.\n\n IMPRESSION:\n\n 1. No evidence of acute fracture or parenchymal injury.\n 2. Bibasilar atelectasis and hypoventilatory changes within the lungs.\n 3. Coronary artery calcification.\n 4. Prostatic hypertrophy.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-09 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 1051553, "text": " 2:35 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: To assess hardware\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with type 2 dens fracture s/p fusion\n REASON FOR THIS EXAMINATION:\n To assess hardware\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess hardware.\n\n TWO VIEWS CERVICAL SPINE: Compared to CT C-spine of . There is\n posterior fusion above and below the type 2 dens fracture, with the superior\n and inferior components in good alignment. The previously described fractures\n at C1 and C4 are not well assessed. The lateral radiograph images only to the\n level of superior endplate of C6. There is a longstanding fusion of C5 and\n C6. There is minimal (1 mm) anterolisthesis of C3 on C4. Flexion and\n extension views were not performed. Severe uncovertebral degenerative change\n and hypertrophy are noted on the AP view. Surgical staples remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050241, "text": " 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n assess trauma\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP trauma chest radiograph.\n\n INDICATION: Motor vehicle collision.\n\n AP chest radiograph given on trauma board and portable technique. There are\n very low lung volumes, accounting for crowding of the pulmonary vasculature.\n No large effusion or pneumothorax is detected this supine exam. Mediastinum\n prominence mostly reflects tortuous aorta and supine positioning. No CHF or\n pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2183-12-04 00:00:00.000", "description": "Report", "row_id": 241334, "text": "Sinus rhythm with borderline sinus tachycardia\nRight bundle branch block\nInferior T wave configuration could be in part primary but are nonspecific and\nmay be due to the right bundle branch block\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n\n" }, { "category": "ECG", "chartdate": "2183-12-03 00:00:00.000", "description": "Report", "row_id": 241335, "text": "Sinus tachycardia. Right bundle branch block. Non-diagnostic anterolateral\nQ waves. No previous tracing available for comparison. Clinical correlation\nis suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-07-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1198931, "text": " 12:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? hemorrhagic brain mets, ? midline shift\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with known mets to brain, now with left sided weakness after\n neck surgery\n REASON FOR THIS EXAMINATION:\n ? hemorrhagic brain mets, ? midline shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf TUE 1:58 AM\n No acute hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old man with known metastases to the brain, likely related\n to a lung mass, now with left-sided weakness after neck surgery.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: CT head, . MRI head, .\n\n FINDINGS: No overt change is seen in multiple intracranial hyperdense masses\n and surrounding edema, as detailed in the MRI report. The largest\n lesion is in the right posterior temporal lobe. One lesion is located in the\n posterior pons. There is stable mild effacement of the body of the right\n lateral ventricle. There is no shift of midline structures. No acute\n abnormalities are seen.\n\n New posterior occipital-cervical fusion is better assessed on the concurrent\n cervical spine CT.\n\n IMPRESSION: No overt interval change on noncontrast head CT. MRI would be\n more sensitive for an acute infarction, if clinically indicated.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2101-07-11 00:00:00.000", "description": "C-SPINE (PORTABLE)", "row_id": 1198895, "text": " 4:55 PM\n C-SPINE (PORTABLE) Clip # \n Reason: LEVEL VERIFICATION\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n WET READ: SHSf MON 10:14 PM\n S/p posterior fusion of Occipital calvarium, C2-4., lower spine not included\n on lateral. Imaged upper spine has preserved alignment. Hardware over skull\n is incompletely assessed. ET/NG incompletely assessed.\n\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Cervical spine, .\n\n CLINICAL HISTORY: Patient with posterior fusion. Level verification.\n\n FINDINGS: The patient is status post fusion of the occiput down to the level\n of C4. There are no signs of hardware-related complications. There is\n generalized demineralization. Pre-vertebral soft tissues are grossly normal.\n Cervical spine is not well seen below the level of C4.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1198932, "text": "WHITE, P. ORTHO TSICU 12:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? hemorrhagic brain mets, ? midline shift\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with known mets to brain, now with left sided weakness after\n neck surgery\n REASON FOR THIS EXAMINATION:\n ? hemorrhagic brain mets, ? midline shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute hemorrhage.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2101-07-12 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 1198946, "text": " 4:05 AM\n MR W& W/O CONTRAST Clip # \n Reason: ? spinal cord integrity\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cervical fusion for spinal mets, developed left sided\n weakness post op\n REASON FOR THIS EXAMINATION:\n ? spinal cord integrity\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n Indication: Spinal cord integrity. Patient with history of spinal metastasis.\n\n Technique: Multiaxial multisequence MRI images of the cervical spine were\n obtained without the administration of contrast.\n\n Comparison: ct from and priors.\n\n Findings:\n\n Postsurgical changes s/p occipito-cervical fussion. The metal artifact\n difficults the evaluation of the spinal canal from C2 to C5 levels.\n\n Again noted there is a 4.7 x 4.8 cm enhancing mass involving the right aspect\n of C2 vertebral body/lateral mass engulfing the right vertebral artery and\n obstructing the right neuroforamina. No evidence of involvement of the spinal\n canal at this level. Again noted enhancing lesions in the posterior fossa\n involving the pons and right temporo-occipital region.\n\n At C5-C6, there is a 5 mm retrolisthesis. There is also a posterior osteophyte\n indenting and flattening the anterior aspect of the spinal cord. The spinal\n cord signal is normal.\n\n At C6-C7, There is a posterior osteophyte indenting and flattening the\n anterior aspect of the spinal cord. The spinal cord signal is normal.\n\n Impression:\n\n 1. Enhancing mass involving the right aspect of C2 vertebral body/lateral mass\n engulfing the right vertebral artery and obstructing the right neuroforamina.\n No evidence of involvement of the spinal canal at this level.\n\n 2. Degenerative changes as described above worse at c5-6 and c6-7 with\n posterior osteophytes indenting and flattening the spinal cord but no evidence\n of spinal cord signal abnormality.\n\n\n (Over)\n\n 4:05 AM\n MR W& W/O CONTRAST Clip # \n Reason: ? spinal cord integrity\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198800, "text": " 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Worsening hypoxia\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with metastatic nsclc\n REASON FOR THIS EXAMINATION:\n Worsening hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Metastatic non-small cell lung cancer with worsening\n hypoxia.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Heart size is unremarkable. Widening of the right hilar contour due to known\n infrahilar mass is redemonstrated. No new abnormalities to suggest interval\n development of acute process is noted. No interval pleural effusion\n development is seen. Asbestos-related pleural plaques are demonstrated.\n\n IMPRESSION:\n No abnormalities to explain patient's symptoms within the limitations of this\n study technique. If clinically warranted, correlation with cross-sectional\n imaging might be considered.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1198933, "text": " 1:05 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? migration of hardware in cspine\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cspine fusion for mets to C2 and with left sided weakness\n after surgery\n REASON FOR THIS EXAMINATION:\n ? migration of hardware in cspine\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf TUE 2:59 AM\n 1. Status post posterior fusion in the upper cervical spine with no evidence\n of hardware material in the cervical canal.\n\n 2. Metastasis at C2 with a large soft tissue component on the right.\n\n 3. Large cervical lymph nodes concerning for metastasis.\n\n Please note that cord is suboptimally evaluated on CT. If high clinical\n concern, consider MRI.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post C-spine fusion for metastasis to C2 and left-sided\n weakness after surgery.\n\n TECHNIQUE: CT C-spine without contrast. Coronal and sagittal reformatted\n images provided.\n\n COMPARISON: MR cervical spine, . CT neck with soft tissue and\n bone algorithm images from \"Health Alliance\", .\n\n FINDINGS: A large soft tissue mass is again seen completely destroying the\n right vertebral body, right lateral mass, and right lateral lamina of C2. The\n mass extends anteriorly, laterally, and inferiorly, abutting the right lateral\n mass of C3 without evidence of erosion. The mass measures 4.9 x 4.2 cm\n (2:30).\n\n The patient is status post posterior occipital-cervical fusion, with gas in\n the surrounding soft tissues as expected in the immediate postsurgical\n setting. There is a midline occipital plate with 3 screws, left C2 through C4\n translaminar screws, and right C3 and C4 translaminar screws. The left C3\n screw extends into the anterior margin of the C3-4 facet joint. The right C4\n screw extends into the C4-5 facet joint. There is no evidence for hardware\n loosening, and no violation of the neural foramina or spinal canal. There is\n a minimal anterolisthesis of C2 on C3, more pronounced than on the prior\n exams.\n\n There are multilevel degenerative changes in the cervical spine, better seen\n on the recent MRI.\n\n There is a left level 3a node measuring 2.5 x 2.2 x 4.7 cm (2:42 and 400:19),\n (Over)\n\n 1:05 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? migration of hardware in cspine\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n stable since . There is a left level 2a node (posterior to the\n submandibular gland but anterior to the sternocleidomastoid muscle) measuring\n 2.2 x 2.1 x 3.1 cm (2:30 and 400:16), slightly larger than on .\n\n The patient is intubated. A calcified pleural plaque is again seen in the\n imaged upper left hemithorax, suggesting prior asbestos exposure, as other\n bilateral calcified pleural plaques are present on the torso CT.\n\n Multiple intracranial hyperdense masses are again noted, as seen on concurrent\n head CT and the head MRI. There is a mucus retention cyst in the\n inferior left maxillary sinus.\n\n IMPRESSION:\n\n 1. Status post posterior occipital-C4 fusion without evidence of hardware\n migration into the spinal canal or neural foramina.\n\n 2. Large right lateral paravertebral mass at C2 and C3 levels, completely\n destroying the right aspect of C2, similar to the prior exams.\n\n 3. Multilevel cervical DJD is better assessed on the cervical spine\n MRI.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1198934, "text": "WHITE, P. ORTHO TSICU 1:05 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? migration of hardware in cspine\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cspine fusion for mets to C2 and with left sided weakness\n after surgery\n REASON FOR THIS EXAMINATION:\n ? migration of hardware in cspine\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Status post posterior fusion in the upper cervical spine with no evidence\n of hardware material in the cervical canal.\n\n 2. Metastasis at C2 with a large soft tissue component on the right.\n\n 3. Large cervical lymph nodes concerning for metastasis.\n\n Please note that cord is suboptimally evaluated on CT. If high clinical\n concern, consider MRI.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-06 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1198269, "text": ", W. NMED FA11 4:15 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Extension into brain?\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new onset C-spine mass with radicular symptoms.\n REASON FOR THIS EXAMINATION:\n Extension into brain?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Multiple rim-enhancing lesions with surrounding edema and blood products\n within the lesions suggestive of metastatic disease. The lesions involve\n predominantly the right frontal lobe, right posterior temporal lobe, pons, as\n well as the splenium of corpus callosum. Mild mass effect is seen on the\n sulci, but no midline shift seen or brain herniation identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198105, "text": " 2:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any acute or infiltrative process?\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new onset shoulder pain and brainstem mass\n REASON FOR THIS EXAMINATION:\n Any acute or infiltrative process?\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 80-year-old male patient with new onset shoulder pain and\n brainstem mass. Any acute or infiltrative process?\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. No previous chest examination is available for\n direct comparison. On the frontal view, mild cardiac enlargement is seen, but\n no evidence of pulmonary congestion is found within the pulmonary circulation.\n There is a large central right-sided hilar mass dominating the chest findings\n on the frontal view. This is consistent with either primary lung tumor or\n secondary deposit. One cannot identify any new pulmonary peripheral\n abnormalities or local bony destruction on this single view chest examination.\n Thoracic aorta is moderately elongated and widened.\n\n IMPRESSION: Large size central pulmonary right-sided hilar mass. No previous\n chest examinations available for comparison. Described findings would benefit\n from a chest CT for further delineation of the process.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-06 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1198268, "text": " 4:15 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Extension into brain?\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new onset C-spine mass with radicular symptoms.\n REASON FOR THIS EXAMINATION:\n Extension into brain?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:45 AM\n PFI: Multiple rim-enhancing lesions with surrounding edema and blood products\n within the lesions suggestive of metastatic disease. The lesions involve\n predominantly the right frontal lobe, right posterior temporal lobe, pons, as\n well as the splenium of corpus callosum. Mild mass effect is seen on the\n sulci, but no midline shift seen or brain herniation identified.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with cervical spine mass, for further\n evaluation of the brain.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility, and diffusion\n axial images of the brain were acquired before gadolinium. T1 axial and\n MP-RAGE sagittal images acquired following the administration of gadolinium.\n\n FINDINGS: There are multiple rim-enhancing lesions with blood products\n identified in the brain. The largest lesion is identified in the right\n posterior temporal lobe measuring approximately 4 cm in size. Additional\n approximately 2-cm lesions are seen in the periventricular region of the right\n frontal lobe at right frontal convexity, and lesion is seen involving the\n brainstem and the posterior part of the pons. There is edema seen surrounding\n these lesions. A small lesion is seen in the region of splenium of corpus\n callosum. There is no midline shift identified, but mass effect is seen on\n the ventricles and sulci. There is no hydrocephalus.\n\n Small vessel disease is seen in the periventricular white matter. Brain\n atrophy is seen.\n\n Again noted is a mass involving the C2 vertebra visualized on the sagittal T1\n images. This was further evaluated with cervical spine MRI.\n\n IMPRESSION: Multiple rim-enhancing lesions with surrounding edema and blood\n products within the lesions suggestive of metastatic disease. The lesions\n involved predominantly the right frontal lobe, right posterior temporal lobe,\n pons, as well as the splenium of corpus callosum. Mild mass effect is seen on\n the sulci, but no midline shift seen or brain herniation identified.\n\n (Over)\n\n 4:15 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Extension into brain?\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-07-05 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 1198151, "text": " 10:15 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: Please describe extent of C-spine mass\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new onset C-spine mass with radicular symptoms.\n REASON FOR THIS EXAMINATION:\n Please describe extent of C-spine mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with C-spine mass with radicular symptoms. Whole\n spine MRI is requested.\n\n COMPARISON: MRI cervical spine and CT torso .\n\n TECHNIQUE: Sagittal T1, T2 and STIR sequences of the cervical, thoracic and\n lumbar spine were obtained with axial T2-weighted scans. Post-IV\n administration of contrast, sagittal and axial scans were obtained.\n\n FINDINGS: 5 x 3.8 cm heterogeneous signal intensity mass, hypointense on T1\n and heterogeneously hyperintense on STIR sequences. Mass is obliterating the\n C2-3 neural foramen. There is no intraspinal extension. Mass is encasing the\n right vertebral artery. The visualized portions of the brain parenchyma\n reveals multiple rim-enhancing lesions in the right cerebellar hemisphere and\n the brainstem. Rest of the vertebral bodies are normal in height and signal\n intensities. There is grade 1 retrolisthesis of C5 over C6. Vertebral body\n signal intensities and height are normal. Posterior elements appear normal.\n Spinal cord shows normal morphology and signal intensity. Pre- and\n para-spinal soft tissues are unremarkable.\n\n THORACIC SPINE: Vertebral body height and signal intensity of the thoracic\n spine appear normal. Bridging osteophytes seen at multiple levels in thoracic\n spine, most prominent at T8-T9 level. There is no spinal canal compromise. A\n left perihilar mass is seen measuring 8.3 x 5 cm. This correlates with the\n left perihilar mass lesion seen on CT scan. The spinal cord terminates at\n T12-L1.\n\n LUMBAR SPINE: Spinal hardware is seen extending from T11 to L5 vertebra with\n extensive artifacts. Post-surgical changes are seen of anterior and posterior\n fusion. Marked geometric symmetric distortion from metallic hardware. There\n is no spinal cord compression or any significant spinal canal encroachment\n seen at this level.\n\n IMPRESSION: Heterogeneous signal intensity mass involving the lateral mass of\n C2 vertebra, likely a bony metastasis. Visualized lung parenchyma reveals\n multiple rim-enhancing lesions in the right cerebral hemisphere and brainstem\n likely metastasis. Further evaluation with brain MRI is recommended.\n (Over)\n\n 10:15 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: Please describe extent of C-spine mass\n Admitting Diagnosis: NECK MASS\n Contrast: MAGNEVIST Amt: 19\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2101-07-05 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1198128, "text": " 6:28 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSClip # \n Reason: Please evaluate for primary malignancy\n Admitting Diagnosis: NECK MASS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with C2 lesion, concern for met\n REASON FOR THIS EXAMINATION:\n Please evaluate for primary malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 9:22 PM\n 0. Mildly enhancing right posterior hilar mass, 7.8 x 6.2 x 3.3 cm. Subcarinal\n enhancing node, 29 x 9 mm.\n 1. Study not designed for pulmonary embolism assessment, but equivocal filling\n defects in the RUL and RLL segmental branches adjacent to the hilar mass. If\n clinical concern for PE is high, recommend repeating a dedicated CTA chest in\n the morning.\n 2. 1.2 cm right basilar pleural calcification. Mild centrilobular emphysema\n with upper zone predominance. No PTX or pleural effusions.\n 3. Right tracheal diverticulum vs contained tracheal perforation from prior\n procedure (image 3:9).\n 4. 1.8 cm soft tissue nodule in the left anterior abdomen, concerning for\n peritoneal implant.\n 5. 1-cm rim-enhancing lesion at the right hepatic dome (image 3:45).\n 6. Mild-to-moderate cardiomegaly. Marked coronary artery disease. Marked\n atherosclerotic disease throughout.\n 7. 6.2 cm left upper pole exophytic renal cyst.\n 8. Fatty atrophy of the pancreas. 1-cm round nodule anterior to the spleen\n (image 3:60) and 7 mm in the atrophic pancreatic body, cannot exclude\n additional intraperitoneal implants. No adrenal nodule.\n 9. T11-S1 posterior spinal fusion.\n 10. Coarse prostate calcifications. Small fat-containing L inguinal hernia.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with C2 lesion concerning for met. Study to evaluate for\n primary malignancy.\n\n TECHNIQUE: Multidetector CT acquired axial images from the lung apices to the\n pubic symphysis were displayed with 5 mm slices post oral contrast and with\n and without IV contrast. IV contrast studies were performed after the\n administration of 130 mL of Optiray. Coronally and sagittally reformatted\n images were displayed with 5 mm slice thickness.\n\n COMPARISONS: There are no comparison studies.\n\n FINDINGS:\n\n CT OF THE CHEST: Large poorly enhancing heterogeneous soft tissue density\n mass located posterior to right hilum extending to posterior pleural surface\n measuring 3.1 x 6.0 x 6.8 cm. Adjacent also to right main and lower lobe\n (Over)\n\n 6:28 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSClip # \n Reason: Please evaluate for primary malignancy\n Admitting Diagnosis: NECK MASS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bronchus, which are both still patent, there is an adjacent lymph node which\n measures 1.2 x 0.8 cm. There is a small left upper lobe lung nodule. There\n is evidence of extensive vascular calcifications including coronaries,\n evidence of emphysema bilaterally and pleural calcifications bilaterally.\n\n No lymph nodes were observed in the visualized portion of the neck or axilla.\n No lymph nodes were noted in the mediastinum. There appears to be a tracheal\n diverticulum at the level of the thighs. No filling defects are seen within\n the main pulmonary artery or segmental branches on this non-CTA study. Heart\n appears normal size with clinically insignificant amount of pericardial\n effusion.\n\n CT ABDOMEN WITH AND WITHOUT CONTRAST: Liver parenchyma appears to be\n relatively homogeneous with the appearance of an isolated nodule appearing on\n series 3, image 45 in what appears to be segment VIII of the liver. Lesion\n appears hypodense and irregular on arterial phase of study with some\n peripheral enhancement, though not completely characterized on this exam.\n\n The remainder of liver appears of normal texture and density. The patient has\n had a cholecystectomy. Left and right kidneys appear normal in size and\n shape. Right adrenal gland appears normal.\n\n Left adrenal gland (series 3, image 57) appears nodular in character. Spleen\n appears normal with a small enhancing area proximal to the spleen slightly\n medial and anterior most likely representing a splenule.\n\n Fatty atrophic pancreas with a 7-mm arterial enhancing soft tissue nodule\n (3:59) is seen within the body. No ductal dilatation is seen.\n\n Stomach, small and large bowel appear normal with normal course and caliber.\n No retroperitoneal or mesenteric lymphadenopathy is noted; however, there is a\n 1.8 cm round nodule located in the mesentery in the left upper quadrant\n (3:65).\n\n There is a large 6.3 x 5.2 cm (3:53) fluid-filled thin-walled cyst within the\n left upper quadrant without evidence of wall nodularity of soft tissue\n components. This appears to be separate from the left kidney and spleen, such\n that the origin of this retroperitoneal cyst is unclear.\n\n CT PELVIS WITH CONTRAST: There is a fat containing left inguinal hernia. No\n pathologically significant inguinal lymph nodes are seen. There are coarse\n calcifications in the prostate. There is no free air or fluid in the pelvis\n or abdomen.\n\n BONE WINDOWS: There is surgical spinal fusion with stable postoperative\n (Over)\n\n 6:28 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSClip # \n Reason: Please evaluate for primary malignancy\n Admitting Diagnosis: NECK MASS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n changes between T11 and S1. There is also extensive degenerative joint\n disease of the vertebra. Otherwise, there are no sclerotic or lytic lesions\n suspicious for malignancy seen.\n\n IMPRESSION:\n 1. Lung mass measuring 3.1 x 6.0 x 6.8 cm proximal to the right hilum with a\n single adjacent enlarged hilar lymph node concerning for primary malignancy.\n\n 2. 10 mm hypodense/hypoenhancing focus Segment VIII in the right liver lobe\n is not completely characterized on this exam. Small/early metastasis can not\n be excluded.\n 3. 7 mm arterial hyperenhancing nodule in the body of the pancreas.\n Differential includes a primary pancreatic tumor (such as a neuroendocrine\n tumor) or metastasis.\n 4. 8 mm soft tissue nodule in the mesentery in the left upper quadrant\n concerning for metastasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1198358, "text": " 9:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for evolution, hemorrhage\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with brain mets, new headache\n REASON FOR THIS EXAMINATION:\n Evaluate for evolution, hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:12 PM\n 1. Stable-appearing metastatic disease with no evidence of new hemorrhage.\n 2. Left maxillary sinus disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with brain mets, now with new headache. Evaluate\n for evolution, hemorrhage.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: MR of the head with and without contrast from .\n\n FINDINGS: There are multiple hyperdense lesions identified in the brain,\n stable from prior study, with no evidence of any new hemorrhage. The largest\n lesion is located in the right posterior temporal lobe with additional lesions\n seen in the periventricular region of the right frontal lobe. There is also a\n lesion present in the posterior pons. There is extensive vasogenic edema seen\n surrounding these lesions, stable from prior study. There is mild effacement\n of the body of the right lateral ventricle unchanged from the prior study.\n There is no shift of the normally midline structures.\n\n There is mucosal thickening in the left maxillary sinus, with clear appearing\n mastoid air cells bilaterally.\n\n IMPRESSION:\n 1. Stable-appearing metastatic disease with no evidence of any new\n hemorrhage.\n 2. Mucosal thickening of left maxillary sinus.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1198359, "text": ", W. NMED FA11 9:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for evolution, hemorrhage\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with brain mets, new headache\n REASON FOR THIS EXAMINATION:\n Evaluate for evolution, hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable-appearing metastatic disease with no evidence of new hemorrhage.\n 2. Left maxillary sinus disease.\n\n" }, { "category": "ECG", "chartdate": "2101-07-08 00:00:00.000", "description": "Report", "row_id": 247563, "text": "Atrial fibrillation with moderate ventricular response. Occasional ventricular\npremature beats. Diffuse T wave changes that are non-specific. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2160-01-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1169544, "text": " 3:17 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with persistent fever and recent PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fever, recent pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing basal\n opacities have completely resolved. Bilateral apical thickening that is\n symmetrical. Mild peribronchial thickening, notably at the right lung base,\n consistent with chronic bronchitis. Normal size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-01-26 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1169615, "text": " 11:16 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for GI pathology, lung pathology\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man h/o , smoking history, with cyclic fevers over past\n month, with associated hypotension.\n REASON FOR THIS EXAMINATION:\n please eval for GI pathology, lung pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE CHEST, ABDOMEN, AND PELVIS, \n\n STUDY INDICATION: 57-year-old man with history of ulcerative colitis and long\n smoking history with cyclic fevers over the past month with associated\n hypotension. Evaluate for GI and lung pathology.\n\n TECHNIQUE: CT scan of the chest, abdomen, and pelvis was obtained with\n intravenous iodinated contrast from thoracic inlet to the perineum in the\n abdominal portal venous phase. Oral bowel contrast was administered.\n Multiplanar sagittal and coronal reformats were generated.\n\n Compared to multiple prior studies, including CT scan of , MR\n of and CT scan of .\n\n FINDINGS:\n\n CT SCAN OF THE CHEST: There has been interval removal of the right\n trans-subclavian PICC line.\n\n There is complete interval resolution of bilateral basal consolidation with\n minimal residual nodular atelectasis in the posterior costophrenic angles.\n Pleural effusions have completely resolved. Lung parenchyma is unremarkable\n except for previously described centrilobular emphysema in the upper lobes and\n minimal bilateral apical scarring, unchanged. Airways are patent. No\n mediastinal, hilar, axillary, or internal mammary adenopathy. No pericardial\n effusion. Aorta, pulmonary artery, and great thoracic vessels are\n unremarkable.\n\n CT SCAN OF THE ABDOMEN: Liver, adrenals, kidneys, pancreas, and spleen are\n unremarkable. The gallbladder is contracted without intra- or extra-hepatic\n biliary dilation. No adenopathy or ascites. Bowel demonstrates no\n abnormality.\n\n CT SCAN OF THE PELVIS: The patient is status post colectomy. The previously\n described thickening of the terminal ileum proximal to the ileostomy in the\n right lower quadrant is no longer seen. Bladder and prostate are unremarkable.\n No free fluid in the pelvis.\n\n (Over)\n\n 11:16 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for GI pathology, lung pathology\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n No bone lesions.\n\n IMPRESSION:\n\n Interval resolution of the bilateral basal consolidation and pleural\n effusions.\n\n No abnormality in the chest, abdomen, or pelvis to suggest an infectious\n focus.\n\n" }, { "category": "ECG", "chartdate": "2160-01-25 00:00:00.000", "description": "Report", "row_id": 302365, "text": "Sinus rhythm. RSR' pattern in lead V1 is likely a normal variant. Compared to\nthe previous tracing of the findings are similar.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2176-09-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 694328, "text": "DIVISION OF CARDIOLOGY CCU COMPREHENSIVE ADMISSION NOTE\n .\n .\n .\n OUTPATIENT CARDIOLOGIST: Kavarni ()\n .\n PCP: , MD\n .\n .\n CHIEF COMPLAINT: Post Cardiac Catheterization Observation\n .\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n .\n The pt originally presented to an OSH on with 3 weeks of headache\n in the setting on uncontolled HTN, and progressive SOB. On the day of\n transfer () the pt experienced nausea and vomitting, and became\n hypotensive to 50/p following admission of BP meds. Thus the pt's\n Lisinopril and Imdur were discontinued, and the BP responded to IVF\n boluses. The pt was started on coumadin for unclear reasons. Pt. had\n several NSVT runs of beats. CEs negative x1 at OSH. TTE revealed\n EF 15% down from previous 20%. Pt. transferred to for management\n of VTach episodes by EP and possible cardiac catheterization.\n .\n While on the service ( though the morning of ) the pt was\n evaluated for acute systolic CHF excerbation. The patients carvediolol\n was titrated up. TTE was repeated confirming an EF of 15% and the pt\n was sent for cardiac catheterization following stabilization of his\n creatinine.\n .\n While in the Cardiac Catheterization today the pt was noted to half\n clean coronaries and a wedge of 22. While attempting to shoot the pt's\n renal arteries the pt experienced sudden onset of sharp abdominal pain.\n General Surgery was consulted for evaluation of potential visceral\n organ embolization. The pt remained hemodynamically stable and was\n given IV fentanyl for pain control. The pt was subsequently transferred\n to the CCU for overnight observation.\n .\n On review of systems, s/he denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n .\n PAST MEDICAL HISTORY:\n 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n - Coronary artery disease\n - Myocardial Infarction in , status post percutaneous\n coronary intervention, vessel intervene unknown.\n -systolic congestive heart failure recurrent with ejection\n fraction of 20%. Has been hospitalized for exacerbations x3 w/\n admission to hospital in D.R. several months ago requiring intubation.\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 3. OTHER PAST MEDICAL HISTORY:\n - bilateral renal artery stenosis status post renal artery\n stenting bilaterally.\n - subarachnoid hemorrhage secondary to cerebral aneurysm s/p\n aneurysm clipping in .\n -PVD s/p left axillofemoral bypass graft, \n .\n HOME MEDICATIONS:\n Felodipine 5mg PO Daily\n ASA 81mg PO Daily\n Plavix 75mg PO Daily\n Digoxin 125mcg PO BID\n Lasix 40mg PO Daily\n .\n MEDICATIONS ON TRANSFER TO :\n ASA 81mg daily\n Plavix 75mg daily\n Warfarin 5mg daily\n Spironolactone 25mg QAM\n Carvedilol 12.5mg \n Furosemide 100mg Qam\n Imdur 30mg daily\n Colace 100mg \n Zofran 4mg Q8\n Ambien 10mg QHS\n Heparin SC TID.\n .\n .\n ALLERGIES: Tylenol, Potassium\n .\n .\n SOCIAL HISTORY: The patient is a former smoker, greater than\n 30 pack years. Is not smoking at present. He drinks\n socially. Denies drug use. He has been disabled for 8 years.\n Formerly worked in a fabric factory. He is divorced, but\n lives with his previous spouse.\n -Tobacco history: 30 pack years of smoking, quit\n -ETOH: None\n -Illicit drugs: None\n .\n .\n FAMILY HISTORY:\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n .\n .\n PHYSICAL EXAMINATION:\n VS: T=97.8 BP 142/97 HR80 RR18 100O2\n GENERAL: Sleeping but AOX3. NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: RIJ in place with dressing with small amount of blood. Supple\n with JVP of 7 cm.\n CARDIAC: Horizontal scar on Left superior chest. Quiet heart sounds.\n Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Bibasilar rales R>L.\n ABDOMEN: Soft, mild epigastic tenderness. No rebound or guarding. No\n HSM or tenderness.\n EXTREMITIES: No c/c/e. Cool extremities.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Popliteal 1+ DP 2+ PT 1+ Right radial wrist wrapped.\n Left: Carotid 2+ Popliteal 1+ DP 2+ PT 1+\n .\n LABS/STUDIES\n EKG: NSR at 75, LVH, right atrial enlargement, early repolarization,\n <1mm ST dep V5-V6. Unchanged from prior.\n .\n CXR: ()\n As compared to the previous radiograph, the extent of predominantly\n right pulmonary edema are unchanged. No newly occurred focal\n parenchymal opacities. The size of the cardiac silhouette is a\n minimally decreased. Unchanged small bilateral pleural effusions.\n .\n OSH echo: \n Dilated LV, Normal RV, dilated left atrium, Aortic sclerosis 1+ AR,\n 4+MR. LEF15%.\n .\n .\n CARDIAC CATH: ()\n Patent LAD, 60-70% distal LCx, patent RCx\n .\n HEMODYNAMICS: Wedge 22\n .\n LABORATORY DATA:\n WBC 14 from 7K\n LFTs WNL\n Cr 2.5 from 2.7\n Lactate 1.0\n .\n .\n ASSESSMENT AND PLAN 59M with EF 15% and vasculopath presenting\n following cardiac catheterization complicated by acute onset abdominal\n pain.\n .\n # Abdominal Pain: Pain occured acutely during cardiac cath as team was\n attempting to maneuver from left subclavian down the thoracic aorta. Pt\n was then evaluated by surgical team to r/o mesenteric ischemia\n secondary to embolizaion. Pain now improved. DDx includes visceral\n organ ischemia, dyspepsia, gastritis, less likely ACS, AAA.\n - Serial Abdominal Exams\n - Trend Lactate\n - LFTs, Amylase, Lipase, Creatinine\n - Guaiac Stool\n - NPO\n .\n # CORONARIES: Hx of CAD s/p stenting. Single vessel disease on cath\n today (see above)\n - Cont Aspirin, Plavix, Statin, Beta-Blocker\n .\n # PUMP: EF of 15% on Echo with severe global left ventricular\n hypokinesis. ACEi held in setting of his ARF. No clinical signs of\n fluid overload.\n - Post-Cath IVF\n - Holding ACEi in setting of increased creatinine\n .\n # RHYTHM: Rate controlled in NSR\n - Cont tele\n .\n # ARF: His creatinine has improved during his admission here. Cr 2.5\n from 2.7\n - Cont to trend renal function\n .\n # ?Diabetes: Prior chart noted a history of DMII. Hemoglobin A1C was\n 5.9%.\n - Holding off finger sticks\n .\n CODE: Full\n .\n COMM: \n .\n DISPO: CCU for observation. Likely callout to tomorrow\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694331, "text": "Embolization, cholesterol (Atheroembolization)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694332, "text": "Embolization, cholesterol (Atheroembolization)\n Assessment:\n Action:\n Response:\n Plan:\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o 6 out of 10abd pain\n Action:\n Pt tried to use commode x2 with no stool and no relief from pain , pain\n meds and aluminum mag po\n Response:\n Pain decreased to 4 out of 10and pt was able to rest and sleep\n Plan:\n Continue to monitor and treat pain\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694494, "text": ".\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n .\n presenting following cardiac catheterization complicated by acute onset\n abdominal pain..\n . Pt evaluated by surgical team to r/o mesenteric ischemia secondary to\n embolizaion. Pain now improved. DDx includes, dyspepsia, gastritis.\n Started on iv famodadine ,po antacids,advancing diet as tol ,last\n vomited 630 am yellow guiac positive has only taken cl liquids .no\n stool.\n SR NO ECT ,BP 130 TO 160 SYSTOLIC ON COREG .RALES IN BASES,SAT 96 RM\n AIR .VOIDED 600 CC AFTER 40 MG PO LASIX .\n CATH SITE RIGHT RADIAL , AS PT FORGETS, MOVES WRIST TOO MUCH DSD\n CHANGED X1,PULSE PRESENT\n CORDIS R IJ REMOVED TODAY,no bleeding\n Renal usn shows renal stent open\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Height:\n Admission weight:\n 64.4 kg\n Daily weight:\n Allergies/Reactions:\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n swelling;\n Potassium\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Hypertension, MI, PVD\n Additional history: MI ' and PCI, Heart Failure, EF 15-20%, Renal\n artery stenosis, s/p renal artery stenting, HTN, ^ cholesterol, PAD (sp\n bipass graft), subarachnoid hemorrhaged/t cerebral aneurysm, s/p\n clipping ', CRI Cr 2.3\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:72\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 522 mL\n 24h total out:\n 1,100 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:24 AM\n Potassium:\n 4.2 mEq/L\n 02:24 AM\n Chloride:\n 101 mEq/L\n 02:24 AM\n CO2:\n 20 mEq/L\n 02:24 AM\n BUN:\n 58 mg/dL\n 02:24 AM\n Creatinine:\n 2.4 mg/dL\n 02:24 AM\n Glucose:\n 126 mg/dL\n 02:24 AM\n Hematocrit:\n 29.0 %\n 02:24 AM\n Valuables / Signature\n Patient valuables: glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:has wallet,declined to have it placed in safe\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu Transferred to: earr 3\n Date & time of Transfer: 4pm\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694366, "text": "Pt is a 59 yo male, transferred to from OSH after 3\n weeks of H/A assoc with HTN. EF noted to be 15%, down from 20%.\n Transferred to for cardiac catheterization and ? EP study d/t\n 5-10 beat runs of SVT. Underwent catheterization showed coronary\n stents were patent. During procedure, pt with c/o abdominal pain and\n diaphoresis. Procedure stopped d/t concern for mesenteric embolic\n event. Surgeon in to assess. Transferred to CCU for further\n monitoring with. In cath lab, pt received 200 mcg fentanyl, 4 mg\n zofran, 5000 units of heparin, 1 mg versed. Pt transferred with R IJ\n venous sheath sutured in place, with ooze. L radial site with hemoband\n in place (Cath via L radial artery).\n R/O Embolization, cholesterol (Atheroembolization)\n Assessment:\n c/o burning, pointing to epigastric area, noradiation, then\n falling asleep. Abdomen flat, soft, +BS\n Action/Response:\n Abdomen monitored, remains flat, soft with +BS\n Antacid given\n Plan:\n Antacid for pain as per team. Keep pt up in chair for now. Continue\n to monitor abdomen and pt\ns c/o pain. Serial Hct and Lactate as per\n surgery\n CV: L radial pulse easily palpable. Fingers warm, brisk capillary\n refill. No numbness. Good movement. SBP130-140\ns/ 80\ns-90. HR 70\n NSR. DP/PT easily palpable.\n Access: RIJ oozing, dressing changed, continued to ooze. Fellow in to\n inject lido/epi into site with resolution of ooze. No hematoma at\n site. L arm #22 PIV.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o 6 out of 10abd pain\n Action:\n Pt tried to use commode x2 with no stool and no relief from pain , pain\n meds and aluminum mag po\n Response:\n Pain decreased to 4 out of 10and pt was able to rest and sleep\n Plan:\n Continue to monitor and treat pain\n" }, { "category": "Nursing", "chartdate": "2176-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694305, "text": "Pt is a 59 yo male, transferred to from OSH after 3\n weeks of H/A assoc with HTN. EF noted to be 15%, down from 20%.\n Transferred to for cardiac catheterization and ? EP study d/t\n 5-10 beat runs of SVT. Underwent catheterization today, showed\n coronary stents were patent. During procedure, pt with c/o abdominal\n pain and diaphoresis. Procedure stopped d/t concern for mesenteric\n embolic event. Surgeon in to assess. Transferred to CCU for further\n monitoring with. In cath lab, pt received 200 mcg fentanyl, 4 mg\n zofran, 5000 units of heparin, 1 mg versed. Pt transferred with R IJ\n venous sheath sutured in place, with ooze. L radial site with hemoband\n in place (Cath via L radial artery).\n R/O Embolization, cholesterol (Atheroembolization)\n Assessment:\n c/o burning, pointing to epigastric area, noradiation, then\n falling asleep. Abdomen flat, soft, +BS\n Action/Response:\n Abdomen monitored, remains flat, soft with +BS\n Pt initially lethargic and falling asleep after c/o pain.\n Later, awake, describing pain . Given 1 mg IV morphine,\n continuing to rub abdomen, stating that he would feel better if he\n could sit up. Ok by Dr. . Placed up in chair\n fell asleep.\n Antacid given. Pain before antacid\n after antacid,\n but pt states pain\nmuch better\n Hct and Lactate level sent as per surgery.\n Plan:\n Antacid for pain as per team. Keep pt up in chair for now. Continue\n to monitor abdomen and pt\ns c/o pain. Serial Hct and Lactate as per\n surgery\n CV: L radial hemo band removed by cardiology fellow @ 1730. Slight\n ooze. L radial pulse easily palpable. Fingers warm, brisk capillary\n refill. No numbness. Good movement. SBP130-140\ns/ 80\ns-90. HR 70\n NSR. DP/PT easily palpable.\n Resp: lungs with bibasilar crackles, on 4 L NP with sats mid 90\n GU: foley draining clear yellow urine. Receiving mucomyst and Na HCO3\n post hydration X 6 hours. Cr 2.5 (2.7)\n ID: as per 3 RN, pt spiked fever last evening to 102, cultures\n sent and PND\nand has been afebrile since midnight. On arrival to CCU,\n po temp 92, rectal temp 97.8. WBC 14.1 (8.1).\n Neuro: Initially lethargic but, oriented X3. c/o transient dizziness\n and pressure in head, but not headache. Dr. aware Follows\n commands, pupils 2mm and briskly reactive. Tongue midline, facial\n expression symmetrical. Moving all extremities equally and to\n resistance. Steady with transfer to chair, supports weight. Primay\n language is Spanish, but speaks and understands English well.\n Skin: intact\n Access: RIJ oozing, dressing changed, continued to ooze. Fellow in to\n inject lido/epi into site with resolution of ooze. No hematoma at\n site. L arm #22 PIV.\n Social: married, lives with wife and son. written HCP, but\n indicates he would like his wife as HCP. have pt complete HCP\n paperwork when narcotics wear off.\n ------ Protected Section ------\n As per 3 RN report, pt\ns last BM was today X2, and also X2\n yesterday\nafter receiving senna, colace and miralax yesterday.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:54 ------\n" }, { "category": "Nursing", "chartdate": "2176-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694287, "text": "Pt transferred to from OSH after 3 weeks of H/A assoc with\n HTN. EF noted to be 15%, down from 20%. Transferred to for\n cardiac catheterization and ? EP study d/t 5-10 beat runs of SVT.\n Underwent catheterization today, showed coronary stents were patent.\n During procedure, pt with c/o abdominal pain and diaphoresis.\n Procedure stopped d/t concern for mesenteric embolic event. Surgeon in\n to assess. Transferred to CCU for further monitoring with. Pt\n transferred with R IJ venous sheath sutured in place, with ooze. L\n radial site with hemoband in place (Cath via L radial artery).\n" }, { "category": "Nursing", "chartdate": "2176-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694297, "text": "Pt is a 59 yo male, transferred to from OSH after 3\n weeks of H/A assoc with HTN. EF noted to be 15%, down from 20%.\n Transferred to for cardiac catheterization and ? EP study d/t\n 5-10 beat runs of SVT. Underwent catheterization today, showed\n coronary stents were patent. During procedure, pt with c/o abdominal\n pain and diaphoresis. Procedure stopped d/t concern for mesenteric\n embolic event. Surgeon in to assess. Transferred to CCU for further\n monitoring with. In cath lab, pt received 200 mcg fentanyl, 4 mg\n zofran, 5000 units of heparin, 1 mg versed. Pt transferred with R IJ\n venous sheath sutured in place, with ooze. L radial site with hemoband\n in place (Cath via L radial artery).\n R/O Embolization, cholesterol (Atheroembolization)\n Assessment:\n c/o burning, pointing to epigastric area, noradiation, then\n falling asleep. Abdomen flat, soft, +BS\n Action/Response:\n Abdomen monitored, remains flat, soft with +BS\n Pt initially lethargic and falling asleep after c/o pain.\n Later, awake, describing pain . Given 1 mg IV morphine,\n continuing to rub abdomen, stating that he would feel better if he\n could sit up. Ok by Dr. . Placed up in chair\n fell asleep.\n Antacid given. Pain before antacid\n after antacid,\n but pt states pain\nmuch better\n Hct and Lactate level sent as per surgery.\n Plan:\n Antacid for pain as per team. Keep pt up in chair for now. Continue\n to monitor abdomen and pt\ns c/o pain. Serial Hct and Lactate as per\n surgery\n CV: L radial hemo band removed by cardiology fellow @ 1730. Slight\n ooze. L radial pulse easily palpable. Fingers warm, brisk capillary\n refill. No numbness. Good movement. SBP130-140\ns/ 80\ns-90. HR 70\n NSR. DP/PT easily palpable.\n Resp: lungs with bibasilar crackles, on 4 L NP with sats mid 90\n GU: foley draining clear yellow urine. Receiving mucomyst and Na HCO3\n post hydration X 6 hours. Cr 2.5 (2.7)\n ID: as per 3 RN, pt spiked fever last evening to 102, cultures\n sent and PND\nand has been afebrile since midnight. On arrival to CCU,\n po temp 92, rectal temp 97.8. WBC 14.1 (8.1).\n Neuro: Initially lethargic but, oriented X3. c/o transient dizziness\n and pressure in head, but not headache. Dr. aware Follows\n commands, pupils 2mm and briskly reactive. Tongue midline, facial\n expression symmetrical. Moving all extremities equally and to\n resistance. Steady with transfer to chair, supports weight. Primay\n language is Spanish, but speaks and understands English well.\n Skin: intact\n Access: RIJ oozing, dressing changed, continued to ooze. Fellow in to\n inject lido/epi into site with resolution of ooze. No hematoma at\n site. L arm #22 PIV.\n Social: married, lives with wife and son. written HCP, but\n indicates he would like his wife as HCP. have pt complete HCP\n paperwork when narcotics wear off.\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694454, "text": ".\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n .\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694453, "text": ".\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n" }, { "category": "Nursing", "chartdate": "2176-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 694458, "text": ".\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n .\n presenting following cardiac catheterization complicated by acute onset\n abdominal pain..\n . Pt evaluated by surgical team to r/o mesenteric ischemia secondary to\n embolizaion. Pain now improved. DDx includes, dyspepsia, gastritis.\n Started on iv famodadine ,po antacids,advancing diet as tol ,last\n vomited 630 am yellow guiac positive has only taken cl liquids .no\n stool.\n SR NO ECT ,BP 130 TO 160 SYSTOLIC ON COREG .RALES IN BASES,SAT 96 RM\n AIR .VOIDED 600 CC AFTER 40 MG PO LASIX .\n CATH SITE RIGHT RADIAL , AS PT FORGETS, MOVES WRIST TOO MUCH DSD\n CHANGED X1,PULSE PRESENT\n PT HAS CORDIS R IJ TO BE REMOVED TODAY BEFORE TRANSFER ,AND ONE PIV .\n RENAL USN SHOWS RENAL STENT PATENT\n" }, { "category": "Physician ", "chartdate": "2176-09-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 694425, "text": "DIVISION OF CARDIOLOGY CCU COMPREHENSIVE ADMISSION NOTE\n .\n .\n .\n OUTPATIENT CARDIOLOGIST: Kavarni ()\n .\n PCP: , MD\n .\n .\n CHIEF COMPLAINT: Post Cardiac Catheterization Observation\n .\n HPI: 59M MI in s/p PTCA w/ stenting to RCA, (Now with patent LAD,\n 60-70% distal LCx, patent RCx as of ), Systolic CHF (EF 15%),\n CRI (baseline Cr 2.3), HTN, SAH to cerebral aneurysm and s/p\n aneurysm clipping in , PVD s/p left axillofemoral bypass ()w/\n recent revision that presents to the CCU today following Cardiac\n Catheterization for recent drop in EF from 20 to 15%.\n .\n The pt originally presented to an OSH on with 3 weeks of headache\n in the setting on uncontolled HTN, and progressive SOB. On the day of\n transfer () the pt experienced nausea and vomitting, and became\n hypotensive to 50/p following admission of BP meds. Thus the pt's\n Lisinopril and Imdur were discontinued, and the BP responded to IVF\n boluses. The pt was started on coumadin for unclear reasons. Pt. had\n several NSVT runs of beats. CEs negative x1 at OSH. TTE revealed\n EF 15% down from previous 20%. Pt. transferred to for management\n of VTach episodes by EP and possible cardiac catheterization.\n .\n While on the service ( though the morning of ) the pt was\n evaluated for acute systolic CHF excerbation. The patients carvediolol\n was titrated up. TTE was repeated confirming an EF of 15% and the pt\n was sent for cardiac catheterization following stabilization of his\n creatinine.\n .\n While in the Cardiac Catheterization today the pt was noted to half\n clean coronaries and a wedge of 22. While attempting to shoot the pt's\n renal arteries the pt experienced sudden onset of sharp abdominal pain.\n General Surgery was consulted for evaluation of potential visceral\n organ embolization. The pt remained hemodynamically stable and was\n given IV fentanyl for pain control. The pt was subsequently transferred\n to the CCU for overnight observation.\n .\n On review of systems, s/he denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n .\n PAST MEDICAL HISTORY:\n 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n - Coronary artery disease\n - Myocardial Infarction in , status post percutaneous\n coronary intervention, vessel intervene unknown.\n -systolic congestive heart failure recurrent with ejection\n fraction of 20%. Has been hospitalized for exacerbations x3 w/\n admission to hospital in D.R. several months ago requiring intubation.\n -PERCUTANEOUS CORONARY INTERVENTIONS: \n 3. OTHER PAST MEDICAL HISTORY:\n - bilateral renal artery stenosis status post renal artery\n stenting bilaterally.\n - subarachnoid hemorrhage secondary to cerebral aneurysm s/p\n aneurysm clipping in .\n -PVD s/p left axillofemoral bypass graft, \n .\n HOME MEDICATIONS:\n Felodipine 5mg PO Daily\n ASA 81mg PO Daily\n Plavix 75mg PO Daily\n Digoxin 125mcg PO BID\n Lasix 40mg PO Daily\n .\n MEDICATIONS ON TRANSFER TO :\n ASA 81mg daily\n Plavix 75mg daily\n Warfarin 5mg daily\n Spironolactone 25mg QAM\n Carvedilol 12.5mg \n Furosemide 100mg Qam\n Imdur 30mg daily\n Colace 100mg \n Zofran 4mg Q8\n Ambien 10mg QHS\n Heparin SC TID.\n .\n .\n ALLERGIES: Tylenol, Potassium\n .\n .\n SOCIAL HISTORY: The patient is a former smoker, greater than\n 30 pack years. Is not smoking at present. He drinks\n socially. Denies drug use. He has been disabled for 8 years.\n Formerly worked in a fabric factory. He is divorced, but\n lives with his previous spouse.\n -Tobacco history: 30 pack years of smoking, quit\n -ETOH: None\n -Illicit drugs: None\n .\n .\n FAMILY HISTORY:\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n .\n .\n PHYSICAL EXAMINATION:\n VS: T=97.8 BP 142/97 HR80 RR18 100O2\n GENERAL: Sleeping but AOX3. NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: RIJ in place with dressing with small amount of blood. Supple\n with JVP of 7 cm.\n CARDIAC: Horizontal scar on Left superior chest. Quiet heart sounds.\n Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Bibasilar rales R>L.\n ABDOMEN: Soft, mild epigastic tenderness. No rebound or guarding. No\n HSM or tenderness.\n EXTREMITIES: No c/c/e. Cool extremities.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Popliteal 1+ DP 2+ PT 1+ Right radial wrist wrapped.\n Left: Carotid 2+ Popliteal 1+ DP 2+ PT 1+\n .\n LABS/STUDIES\n EKG: NSR at 75, LVH, right atrial enlargement, early repolarization,\n <1mm ST dep V5-V6. Unchanged from prior.\n .\n CXR: ()\n As compared to the previous radiograph, the extent of predominantly\n right pulmonary edema are unchanged. No newly occurred focal\n parenchymal opacities. The size of the cardiac silhouette is a\n minimally decreased. Unchanged small bilateral pleural effusions.\n .\n OSH echo: \n Dilated LV, Normal RV, dilated left atrium, Aortic sclerosis 1+ AR,\n 4+MR. LEF15%.\n .\n .\n CARDIAC CATH: ()\n Patent LAD, 60-70% distal LCx, patent RCx\n .\n HEMODYNAMICS: Wedge 22\n .\n LABORATORY DATA:\n WBC 14 from 7K\n LFTs WNL\n Cr 2.5 from 2.7\n Lactate 1.0\n .\n .\n ASSESSMENT AND PLAN 59M with EF 15% and vasculopath presenting\n following cardiac catheterization complicated by acute onset abdominal\n pain.\n .\n # Abdominal Pain: Pain occured acutely during cardiac cath as team was\n attempting to maneuver from left subclavian down the thoracic aorta. Pt\n was then evaluated by surgical team to r/o mesenteric ischemia\n secondary to embolizaion. Pain now improved. DDx includes visceral\n organ ischemia, dyspepsia, gastritis, less likely ACS, AAA.\n - Serial Abdominal Exams\n - Trend Lactate\n - LFTs, Amylase, Lipase, Creatinine\n - Guaiac Stool\n - NPO\n .\n # CORONARIES: Hx of CAD s/p stenting. Single vessel disease on cath\n today (see above)\n - Cont Aspirin, Plavix, Statin, Beta-Blocker\n .\n # PUMP: EF of 15% on Echo with severe global left ventricular\n hypokinesis. ACEi held in setting of his ARF. No clinical signs of\n fluid overload.\n - Post-Cath IVF\n - Holding ACEi in setting of increased creatinine\n .\n # RHYTHM: Rate controlled in NSR\n - Cont tele\n .\n # ARF: His creatinine has improved during his admission here. Cr 2.5\n from 2.7\n - Cont to trend renal function\n .\n # ?Diabetes: Prior chart noted a history of DMII. Hemoglobin A1C was\n 5.9%.\n - Holding off finger sticks\n .\n CODE: Full\n .\n COMM: \n .\n DISPO: CCU for observation. Likely callout to tomorrow\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n 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: 60 minutes.\n Seen on \n ------ Protected Section Addendum Entered By: ,MD\n on: 09:26 ------\n" }, { "category": "ECG", "chartdate": "2176-09-22 00:00:00.000", "description": "Report", "row_id": 147806, "text": "Sinus rhythm. Consider biatrial abnormality. Left ventricular hypertrophy with\nST-T wave abnormalities. Compared to the previous tracing of \nQRS voltage and ST-T wave changes are more prominent.\n\n" }, { "category": "ECG", "chartdate": "2176-09-30 00:00:00.000", "description": "Report", "row_id": 147799, "text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave abnormalities.\nClinical correlation is suggested. Since the previous tracing of same date\nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2176-09-30 00:00:00.000", "description": "Report", "row_id": 147800, "text": "Normal sinus rhythm, rate 79. Borderline biatrial abnormality. Left ventricular\nhypertrophy. Non-specific lateral repolarization changes consistent with left\nventricular hypertrophy and/or myocardial ischemia. Compared to the previous\ntracing of lateral repolarization changes are more pronounced.\n\n\n" }, { "category": "ECG", "chartdate": "2176-09-26 00:00:00.000", "description": "Report", "row_id": 147801, "text": "Sinus rhythm with sinus arrhythmia. Intraventricular conduction delay.\nLeft ventricular hypertrophy by voltage criteria. Non-specific ST segment\nflattening with slight T wave inversion in leads I, aVL and V5-V6 consistent\nwith strain from left ventricular hypertrophy. There is one millimeter\nof J point elevation in lead V1 consistent with early repolarization variant or\nleft ventricular hypertrophy. Compared to the previous tracing the rate is\nslightly faster. Ectopy has resolved. There is a tall P wave in lead II,\nbut not nearly as tall in leads III and aVF, arguing against right atrial\nabnormality.\n\n" }, { "category": "ECG", "chartdate": "2176-09-26 00:00:00.000", "description": "Report", "row_id": 147802, "text": "Sinus rhythm. Occasional premature ventricular contractions. Compared to\ntracing #1 occasional premature ventricular contractions are new. Otherwise,\nno other significant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-09-26 00:00:00.000", "description": "Report", "row_id": 147803, "text": "Sinus rhythm. Anterior ST-T wave abnormalities which are non-specific.\nLeft ventricular hypertrophy. Compared to the previous tracing of \nthere is no significant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 147804, "text": "Sinus rhythm. No significant change compared to the previous tracing of \nexcept for lead placement.\n\n" }, { "category": "ECG", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 147805, "text": "Sinus rhythm. Biatrial abnormality. Left ventricular hypertrophy with\nnon-specific QRS widening and marked repolarization abnormalities consistent\nwith left ventricular strain pattern. Compared to the previous tracing\nof multiple abnormalities as noted persist without major change.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2176-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095135, "text": " 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA, worsening pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with CHF (EF 15%) now with dry cough, fever\n REASON FOR THIS EXAMINATION:\n PNA, worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n Chronic heart failure, rule out pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the extent of predominantly\n right pulmonary edema are unchanged. No newly occurred focal parenchymal\n opacities. The size of the cardiac silhouette is a minimally decreased.\n Unchanged small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2176-09-27 00:00:00.000", "description": "RENAL U.S.", "row_id": 1095405, "text": " 10:25 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: INCREASED CREATINE, R/O RENAL ART STENOSIS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with severe PVD and increased Cr\n REASON FOR THIS EXAMINATION:\n r/o renal artery stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 59-year-old male with severe peripheral vascular disease,\n elevated creatinine status post bilateral renal stents.\n\n The right kidney is quite small in size measuring just under 7 cm in length\n and showing atrophic changes in the cortex, particularly in the upper pole of\n the right kidney. The left kidney is normal in size at 10.4 cm. Neither\n kidney shows evidence of hydronephrosis, stones, or masses. Views of the\n bladder are unremarkable.\n\n Renal Doppler was performed. The peak velocity of the left renal artery near\n the origin and stent was recorded at approximately 60 cm/sec and the peak\n right renal artery near its origin and stent range from 80-110 cm/sec.\n Acceleration times were normal with no spectral broadening. Further color\n flow and Doppler imaging of the kidneys show a paucity of identifiable flow in\n the upper pole of the atrophic right kidney and parvus tardus waveforms of the\n intralobular arteries of the mid and lower third of the right kidney.\n\n Color flow and pulse Doppler of the left kidney show a normal acceleration\n time and waveforms of the left renal artery at the hilus as well as the\n intrarenal waveforms. Resistive indices were normal on the left side, ranging\n up to 0.71. RIs of the right kidney are not considered accurate or calculable\n due to the parvus tardus waveforms.\n\n CONCLUSION: Small atrophic right kidney, particularly in the upper pole\n abnormal intraparenchymal waveforms, but no evidence of increased velocities\n at the level of the aorta and right renal artery stent.\n\n Normal waveforms both in the proximal left renal artery near the stent and in\n the more peripheral intraparenchymal renal arteries on the left side.\n\n\n\n\n\n\n\n (Over)\n\n 10:25 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: INCREASED CREATINE, R/O RENAL ART STENOSIS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2176-09-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1094675, "text": " 10:30 PM\n CHEST (PA & LAT) Clip # \n Reason: Pulmonary edema?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with acute exacerbation of CHF\n REASON FOR THIS EXAMINATION:\n Pulmonary edema?\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Acute exacerbation of CHF, question pulmonary edema.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Moderate cardiomegaly has increased. There is a suggestion of minimal\n interstitial pulmonary edema accompanying a new small left pleural effusion.\n Pulmonary vasculature is not particularly engorged. There is no focal\n pulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095725, "text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema, PNA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with dyspnea, cough\n REASON FOR THIS EXAMINATION:\n pulmonary edema, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old male with dyspnea, cough, pulmonary edema or\n pneumonia.\n\n TECHNIQUE: Portable AP upright chest radiograph.\n\n COMPARISON: Portable AP radiograph from .\n\n FINDINGS: Slightly improved mild interstitial pulmonary edema. Unchanged\n mild cardiomegaly. Mediastinum and hila are normal. There is no pleural\n pathology.\n\n IMPRESSION: Slightly improved mild interstitial pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2176-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1094960, "text": " 6:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Does the patient have a pneumonia?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with new cough, chest congestion. Patient needs to stay on\n floor for telemetry monitoring.\n REASON FOR THIS EXAMINATION:\n Does the patient have a pneumonia?\n ______________________________________________________________________________\n WET READ: MBue TUE 7:35 PM\n CARDIOMEGALY. INTERSTITIAL PROMNIENCE AT THE BASES REFLECT PULMONARY\n EDEMA. NO FOCAL CONSOLIDATION IDENTIFIED.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:20 PM ON \n\n HISTORY: New cough and chest congestion.\n\n IMPRESSION: AP chest compared to :\n\n Although the process is largely confined to the right lower lung, there has\n been no appreciable change in either moderate cardiomegaly, mediastinal\n vascular engorgement, and small left pleural effusion, the change is probably\n due to asymmetric pulmonary edema, accompanied by increasing small right\n pleural effusion.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2148-09-01 00:00:00.000", "description": "Report", "row_id": 303189, "text": "Sinus rhythm with slowing of the rate as compared with previous tracing\nof . There is ST-T wave flattening in the limb leads and more prominent\nT wave inversion in leads V1-V4 with ST-T wave flattening in leads V5-V6\nconsistent with active anterolateral ischemic process. Rule out infarction.\nFollowup and clinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-08-31 00:00:00.000", "description": "Report", "row_id": 303190, "text": "Sinus rhythm. Compared to the previous tracing of there are diffuse\nST-T wave changes which are ischemic in appearance and more prominent in the\nanterolateral leads. Followup and clinical correlation are suggested.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 190245, "text": "Sinus tachycardia. Otherwise, without diagnostic abnormality. No previous\ntracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-28 00:00:00.000", "description": "Report", "row_id": 1464111, "text": " 4 ICU NPN 0700-1900\n19YO BU studentwith HX depression, on lexapro since admitted with lexapro, demerol OD after fight with boyfriend. This AM took approx 15 (10mg) tabs lexapro & unknown quanity of demerol. In EW tox screen also positive for tylenol, ETOH. Pt MS with somnolence, HR 110-160's, 120's/60's. She was given IVF, charcoal, narcan & ativan. Transferred to for further evaluation.\nMS: Dozing. Easily arousable. Eyelids twitching. Oriented X3. S/B psych\nCV: BP 120'130's. HR 110'130's ST. No VEA noted. c/o feeling dizzy when moving- resolves when activity stopped. IVF at 500 cc hr X2L\nRESP: Sats high 90's on 2L NP. BS clear.\nID: T-max 98.9PO\nGI: Tol water, juice.\nGU: foley. UO adequate.\nSocial: Lives with four roomates. live CT. , sister, boyfriend in to visit with pt. Pt designates mother- as spokesperson.(in FHPA)\n\nA/P; Stable.\n1:1 sitters while in hospital. ? psychiatric hospital once medically cleared per psych rec's.\nCont to assess MS, S&SX serotonin syndrome- N, V, diarrhea, flushing, tremor, autonomic instability, diaphoresis, muscle rigidity, hyperreflexia. Treat symptomatically.\nAdvance diet as tol.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1464112, "text": "npn\npt is 19yo f with h/o depression who presented with overdose of lexapro and demerol. pt also had + etoh screeen and admits to having wine and beer prior to taking pills. pt was found by firends who called 911. family and friends were at bedisde on eves. boyfriend stayed all night. pt continued to be on 1 to 1 sitter overnight.\n\nneuro: pt lethargic on eves. slept most of night shift. oriented x3. a little teary eyed when questioned to why she was here.\n\ncad hr 70 to 80's overnight as compared to st low 100's on eves, b/p 120's/70's no issues.\n\ngi: bs + abd soft. pt had large fromed bm on eves.\n\ngu: ivf ns at 100cc/hr. urine ouput 125 to 200cc/hr of light yellow urine. pt received over 3 liters of ns .\n\nid: temp max 99,\n\nsocial. and siblings visited on eves as well as college friends.\n\nplan: pt has been seen by psychiatry, continue with 1 to 1 sitter, possible transfer to floor in am. pt to be followed up by psych today. , considering psych hospitalization after medically cleared.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-29 00:00:00.000", "description": "Report", "row_id": 1464113, "text": " 4 ICU nursing progress note:\n s/p od: Pt alert and orientated..much more awake..conversing with family and friends. house staff..pt ready to go to medical floor..Seen by psychiatry this afternoon..pt is willing to go to in-house psych facility. To be watched for 24 hrs..??then dc.\nPt foley dc'd..drinking and eating without problems..\n1:1 sitters continues.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1464114, "text": "npn\npt sleeping most of shift, pt is c/o to floor but no beds are avaiable, remains on 1 to 1 sitter. vs stable, mood pleasant no anxiety noted, friends and family in on eves to visit. boyfirend stayed overnight at bedside. pt to be transferred to hosp for follow-up care.\n" }, { "category": "Nursing/other", "chartdate": "2148-04-30 00:00:00.000", "description": "Report", "row_id": 1464115, "text": " 4 ICU nursing progress note:\n Pt awaiting psych placement. VSS..OOB walking in room. Eating and drinking without problem. Continues on 1:1 sitters..Family spending day with pt.\n" } ]

[ { "category": "Radiology", "chartdate": "2180-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991898, "text": " 7:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: preop\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n WET READ: 10:27 PM\n No acute cardiopulmonary process. Hinesperalta\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest dated with no prior radiographs for\n comparison.\n\n INDICATION: Coronary artery disease. Preoperative assessment.\n\n Examination is technically limited due to exclusion of the extreme right lung\n base laterally from the radiograph.\n\n Heart is upper limits of normal in size. The ascending and descending aorta\n are tortuous. The imaged portions of the lungs are clear, but repeat\n radiograph to include the excluded portion of the right lung base laterally is\n recommended to allow complete assessment of the lungs and pleura. This view\n could be repeated at no additional charge to the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 992850, "text": " 9:59 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pneumonia in patient with fever and poor inspitory\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p CABGx4\n REASON FOR THIS EXAMINATION:\n eval for pneumonia in patient with fever and poor inspitory effort\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG with fever.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Streaks of atelectasis are seen at the left base but no evidence of\n acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 992348, "text": " 2:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n FINDINGS: In comparison with the study of , the patient has undergone a\n CABG procedure. Endotracheal tube tip lies approximately 2.5 cm above the\n carina. Right IJ Swan-Ganz catheter extends to the proximal portion of the\n right pulmonary artery. Mediastinal drains are noted and a left chest tube is\n in place without pneumothorax. Nasogastric tube extends to the upper stomach.\n\n\n There is some indistinctness of the pulmonary markings especially in the left\n perihilar area consistent with some elevated pulmonary venous pressure.\n Increased opacification at the left base is consistent with postoperative\n atelectasis.\n\n IMPRESSION: Standard appearance following CABG.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 993076, "text": " 9:02 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p CABGx4\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, evaluate effusions.\n\n CHEST, TWO VIEWS.\n\n The patient is status post sternotomy, with mediastinal clips and overlying\n skin staples. There is prominence of the cardiomediastinal silhouette. There\n is no CHF. There is some residual increased retrocardiac density and some\n atelectasis in the left mid zone and right medial base. There is minimal\n blunting of both costophrenic angles, consistent with small bilateral\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992616, "text": " 2:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man status post chest tube removal.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST: Interval removal of left chest tube, endotracheal\n tube, pulmonary artery catheter, and NG tube. No evidence of pneumothorax.\n Minimal bibasilar atelectasis is seen. Otherwise, lungs are clear. No\n pleural effusion. There is a standard postoperative appearance of the\n cardiomediastinum following median sternotomy.\n\n IMPRESSION:\n\n 1. Interval removal of left chest tube, no evidence of pneumothorax.\n\n 2. Mild bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2180-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992799, "text": " 10:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABg w/hypotension-r/o effusion\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABg w/hypotension-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG with hypotension.\n\n FINDINGS: In comparison with the study of , there is slight haziness at\n the left base without obscuration of hemidiaphragm. Although this could\n represent an area of effusion, it may merely be a reflection of overlying soft\n tissues. If there is serious clinical concern for the possibility of left\n pleural effusion, decubitus view would be most helpful.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-02-04 00:00:00.000", "description": "P CHEST (PRE-OP AP ONLY) PORT", "row_id": 991986, "text": " 11:17 AM\n CHEST (PRE-OP AP ONLY) PORT; REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: PRE-OP\n Admitting Diagnosis: CA\n ______________________________________________________________________________\n FINAL REPORT\n\n UPRIGHT CHEST RADIOGRAPH\n\n INDICATION: Preoperative radiograph.\n\n COMPARISON: .\n\n FINDINGS: On today's radiographic image, the entire lung is depicted. The\n lung parenchyma is completely normal; there no abnormalities in the region of\n the right lower lung or the lung bases. Otherwise, the report is unchanged to\n .\n\n IMPRESSION: No right-sided pulmonary pathology.\n\n DR. \n" }, { "category": "Echo", "chartdate": "2180-02-07 00:00:00.000", "description": "Report", "row_id": 60233, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE FOR CABG procedure\nHeight: (in) 70\nWeight (lb): 158\nBSA (m2): 1.89 m2\nBP (mm Hg): 145/67\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 10:15\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: Mild global LV hypokinesis. Mildly depressed LVEF. No resting\nLVOT 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. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\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\n1. No atrial septal defect is seen by 2D or color Doppler.\n\n2.There is mild global left ventricular hypokinesis (LVEF = 45%). Overall left\nventricular systolic function is mildly depressed (LVEF= 45%).\n\n3.Right ventricular chamber size and free wall motion are normal.\n\n4.There are simple atheroma in the descending thoracic aorta.\n\n5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is\nnot present. No aortic regurgitation is seen.\n\n6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPost CPB\n\n1. Patient is being AV paced and receiving an infusion of phenylephrine.\n\n2. Immediately post bypass the anterior wall and the anterior septum were\nseverely hypokinetic and the mitral regurgitation was moderate in nature.\nSurgeon made aware. With time the anterior wall, lateral wall and\nanteriorseptum looked a bit better and the mitral regurgitation was mild.\n\n3. Aorta intact post decannulation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-02-07 00:00:00.000", "description": "Report", "row_id": 1619862, "text": "~1220 PATIENT ADMITTED FROM OR. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. PSERL. OG IN PLACE, PLACEMENT CHECKED. IV NEO/EPI/LIDOCAINE INFUSING. PACER OFF, REPORTED THAT BOTH LEADS WORK. CT'S PATENT FOR MODERATE UPON ADMISSION. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\nFAMILY IN. INSULIN GTT ADDED.\nPLAN: WARM, WEAN TO EXTUBATE, KEEP S B/P 100.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-02-07 00:00:00.000", "description": "Report", "row_id": 1619863, "text": "weaning\npt reversed, propfol to off- pt responding--placed on cpap with 5 peep-5 ips--abg okay--yet pt not fully awake--unable top lift head off bed--or raise 2 fingers.\nPlan: give pt more time to wake--then extubate.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-07 00:00:00.000", "description": "Report", "row_id": 1619864, "text": "pt recieved from OR still intubated and was weaned via fast track protocol and ABG results. no sx needed this shift. plan to extubate tonight.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-08 00:00:00.000", "description": "Report", "row_id": 1619865, "text": "PATIENT IN SR IN THE 90'S WITH NO ECTOPY , CONTINUES ON LIDOCAINE AT 2, LOW DOSE EPI, WITH GOOD CI, SVO2 60'S. REQUIRED 1LITER OF LR FOR ST DROP IN CVP TO 0, WITH DROP IN U/O. RESP EXTUBATED AT 2130 TO INTIALLY SHOVEL MASK NOW ON 4LNC WITH SATS 97% OR BETTER, BILATERAL BS CLEAR DECREASED AT BASES. CTS DRAINING SEROSAN FLUID, DID DUMP WITH TURN SUBSIDED THEREAFTER.. GU ADEQUATE U/O. GI ABSENT BS SOFT ABDOMEN. STERNUM DSG D/I LEFT LEG DSG REDONE SUTURES INTACT DSD PLACED, ACE WRAP APPLIED. PEDAL PULSES DOPPERABLES.. ENDOCRINE BS CONTROLLED WITH INSULIN DRIP MAX DOSE AT 7, NOW AT 330 AM OFF FOR BS 85. K REPLETED X1. AM LABS PENDING. PATIENT RECEIVING MORPHINE 1-2MG APPROX. Q1-2HRS WITH GOOD RELIEF. PATIENT PLEASANTLY CONFUSED AT TIMES, EASILY REORIENTED...\n" }, { "category": "ECG", "chartdate": "2180-02-07 00:00:00.000", "description": "Report", "row_id": 108674, "text": "Sinus rhythm. Right bundle-branch block. Left atrial abnormality.\nPosterolateral (question inferior) myocardial infarction, age indeterminate.\nST-T wave abnormalities are probably primary. Clinical correlation is\nsuggested. Since previous tracing of further ST-T wave changes\nare present.\n\n" }, { "category": "ECG", "chartdate": "2180-02-04 00:00:00.000", "description": "Report", "row_id": 108675, "text": "Sinus rhythm. Right bundle-branch block. Inferior myocardial infarction.\nCompared to previous tracing of right bundle-branch block is now\npresent.\n\n" } ]

[ { "category": "Echo", "chartdate": "2197-03-18 00:00:00.000", "description": "Report", "row_id": 88595, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 270\nBSA (m2): 2.32 m2\nBP (mm Hg): 109/50\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 09:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSystolic septal flattening (best seen on SAX views) consistent with right\nventricular pressure overload.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA. Normal IVC diameter (>2.1cm) with <50% decrease with\nsniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Low normal LVEF.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Prolonged (>250ms)\ntransmitral E-wave decel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Severe PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\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 mildly dilated. The right atrium is markedly dilated. The\nestimated right atrial pressure is at least 15 mmHg. There is mild symmetric\nleft ventricular hypertrophy with normal cavity size. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). The right ventricular cavity is\nmoderately dilated with moderate global free wall hypokinesis. There is\nabnormal systolic septal motion/position consistent with right ventricular\npressure overload. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The left ventricular inflow pattern\nsuggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen.\nThere is severe pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Borderline left ventricular systolic function with abnormal\nsystolic septal motion consistent with right ventricular pressure overload.\nModerately dilated right ventricle with moderate global free wall hypokinesis.\nSevere pulmonary hypertension. Mildly dilated aortic arch. Moderate tricuspid\nvalve regurgitation.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthere is now severe pulmonary hypertension, moderate dilation and moderate\ndysfunction of the right ventricle, moderate tricuspid regurgitation, and\nborderline left ventricular systolic function. Dr. notified of\nthese findings today at 3:40 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-20 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1230686, "text": " 2:26 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with worsening dyspnea\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL DVT STUDY\n\n INDICATION FOR STUDY: Worsening dyspnea.\n\n Bilateral lower extremity ultrasound studies were performed. The left and\n right common and superficial femoral veins and popliteal veins are widely\n patent and compressible with augmentation of flow. In addition, the peroneal\n and tibial veins are also widely patent and compressible. Normal color flow\n and pulse Doppler was elicited from both lower extremities in all deep veins.\n\n No DVT in left or right lower extremity.\n\n\n" }, { "category": "ECG", "chartdate": "2197-03-18 00:00:00.000", "description": "Report", "row_id": 235297, "text": "Sinus rhythm with a ventricular premature beat and baseline artifact.\nNon-specific diffuse T wave flattening. Compared to the previous tracing\nof bradycardia is absent. The ventricular premature beat and T wave\nflattening are new. The QRS changes in leads V2-V4 could be due to variability\nin lead placement.\n\n" }, { "category": "Radiology", "chartdate": "2197-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230444, "text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 70F with hypoxia, weight gain, hx pulm HTn and pulm fibrosisClinical\n Question: ? volume overload\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old female with pulmonary fibrosis and pulmonary\n hypertension, now presenting with hypoxia.\n\n COMPARISON: Chest radiograph from and chest CT from , .\n\n PORTABLE AP CHEST RADIOGRAPH: Diffuse interstitial opacities correspond with\n patient's known underlying pulmonary fibrosis. However, compared to the scout\n image from chest CT from , there are overall increased\n interstitial opacities. Additionally, there is enlargement of the hilar\n contours and cardiac silhouette. The above collection of findings suggest\n superimposed moderate pulmonary edema. Probable small bilateral pleural\n effusions are also present. No pneumothorax is evident.\n\n IMPRESSION: Probable moderate interstitial pulmonary edema superimposed upon\n background pulmonary fibrosis. The ddx could include fibrosis with\n superimposed interstital pneumonia, though this is considered less likely.\n\n" }, { "category": "Radiology", "chartdate": "2197-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230530, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with IPF, eelvated BNP with fluid gain, worsening hypoxia\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: IPF and worsening hypoxia.\n\n Comparison is made with prior study .\n\n There are unchanged low lung volumes and diffuse interstitial opacities\n consistent with patient's known pulmonary fibrosis. There is no pneumothorax\n or pleural effusion. There are no new lung abnormalities. The main pulmonary\n arteries are enlarged consistent with pulmonary hypertension. Cardiac\n silhouette is unchanged. Suspected mild interstitial edema is stable.\n Minimally increased opacity in the left lower lobe is consistent with\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230605, "text": " 3:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval changes.\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with IPF and R-sided heart failure.\n REASON FOR THIS EXAMINATION:\n Please assess for interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:08 A.M., \n\n HISTORY: Idiopathic pulmonary fibrosis and right heart failure.\n\n IMPRESSION: AP chest compared to and 4:\n\n Lung volumes are low, pulmonary interstitial abnormality is severe, and the\n cardiac silhouette is moderately enlarged. If there has been any change,\n there has been a slight decrease in mediastinal venous engorgement, perhaps\n due to decrease in intravascular volume. There is no pneumonia or pulmonary\n edema.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2126-11-06 00:00:00.000", "description": "Report", "row_id": 99277, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for atrial thrombus.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 168/90\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:12\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. No thrombus/mass in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\nProminent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal 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 diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\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 normal in size. No thrombus/mass is seen in the body of the\nleft atrium. The estimated right atrial pressure is 0-5 mmHg. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Right ventricular chamber size\nand 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. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal\nbiventricular systolic function. No atrial thrombus seen, but left atrial\nappendage is better evaluated with TEE.\n\n\n" }, { "category": "ECG", "chartdate": "2126-11-05 00:00:00.000", "description": "Report", "row_id": 286460, "text": "Sinus rhythm. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2126-11-05 00:00:00.000", "description": "Report", "row_id": 286461, "text": "Baseline artifact. Sinus rhythm. ST-T wave abnormalities. Since the previous\ntracing of ST-T wave abnormalities are new.\n\n" } ]

[ { "category": "ECG", "chartdate": "2142-03-20 00:00:00.000", "description": "Report", "row_id": 197777, "text": "Sinus tachycardia. Delayed R wave transition. Non-specific ST-T wave\nabnormalities. Left axis deviation. Compared to the previous tracing\nof no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2142-03-20 00:00:00.000", "description": "Report", "row_id": 197778, "text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. Left axis deviation.\nIntraventricular conduction delay. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 909413, "text": " 1:00 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for obstruction after ng decompression\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with known sbo.\n REASON FOR THIS EXAMINATION:\n assess for obstruction after ng decompression\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old male with small bowel obstruction, now with NG tube\n placed.\n\n ABDOMEN, SUPINE AND UPRIGHT: There is a nasogastric tube with tip within the\n stomach. There are multiple loops of dilated small bowel, consistent with\n obstruction. The patient is status post colectomy. There is an ostomy in the\n right lower quadrant. There are severe bilateral degenerative changes of the\n hip joints. A 5 mm calcific density projects over the left kidney, compatible\n with a renal stone.\n\n IMPRESSION: Small bowel obstruction. Left renal calculus. Severe\n bilateral degenerative changes of the hip joints.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909531, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with psbo and sagging o2 sats, L infiltrate\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:18 A.M. .\n\n HISTORY: Small bowel obstruction and decreased oxygen saturation.\n\n IMPRESSION: AP chest compared to :\n\n Multifocal infiltrative pulmonary abnormality probably aspiration pneumonia\n has improved generally consistent with resolving pneumonia. Subcutaneous\n emphysema in the left neck has decreased or resolved and pneumomediastinum is\n smaller. There is no definite pneumothorax or appreciable pleural effusion.\n Heart is normal size. Nasogastric tube ends in the stomach. Tip of the right\n subclavian line projects over the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909444, "text": " 8:38 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for causes of low o2 sats\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with psbo and sagging o2 sats\n REASON FOR THIS EXAMINATION:\n eval for causes of low o2 sats\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreasing oxygen saturation.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Hyperinflation and vascular deficiency in the lungs indicate significant\n emphysema. Multifocal opacification has a generally perihilar distribution\n except for the most severe consolidation at the base of the left lung. This\n is probably widespread pneumonia. Heart size is normal. There is no pleural\n effusion or pneumothorax but the pneumomediastinum may be present. The\n esophagus is generally dilated could be due to a distal stricture or\n achalasia, traversed by a nasogastric tube ending in moderately dilated\n stomach. Other loops of bowel seen in the upper abdomen are also dilated.\n Findings were discussed by telephone with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 909420, "text": " 4:23 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: asses sbo\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sbo. assess transition point. NO IV contrast. oral\n contrast only via ngt\n REASON FOR THIS EXAMINATION:\n asses sbo\n CONTRAINDICATIONS for IV CONTRAST:\n cr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with small-bowel obstruction. Assess for\n transition point.\n\n COMPARISON: Abdominal plain films from the same day.\n\n TECHNIQUE: Multidetector CT scanning was performed of the abdomen and pelvis\n after the administration of oral contrast. Intravenous contrast was not\n administered per clinician request. Coronal and sagittal reformations were\n obtained.\n\n FINDINGS: The lung bases demonstrate dependent atelectasis. Visualized heart\n and pericardium demonstrates a small amount of pericardial fluid. A\n nasogastric tube is seen with its tip terminating in the stomach. Oral\n contrast is seen within the fundus of the stomach. It has not progressed\n beyond this point. Multiple loops of dilated small bowel are seen throughout\n the abdomen. The patient is status post colectomy. No clear transition point\n is identified except for what appears to be decompression just prior to the\n right lower quadrant stoma.\n\n Multiple small round hypodensities are seen within the liver which are\n incompletely characterized but likely represent simple cysts. Patient appears\n to be status post cholecystectomy. The spleen and adrenal glands appear\n unremarkable. The pancreas appears atrophic. Multiple round hypodensities\n are seen in the kidneys bilaterally which also likely represent simple cysts.\n No hydronephrosis is seen. No pathologic mesenteric or retroperitoneal\n lymphadenopathy is clearly identified. The vascular structures are not well\n evaluated on this noncontrast study. No free air or free fluid is seen within\n the abdomen. There is no evidence of pneumatosis or focal fluid within the\n mesentery.\n\n CT OF THE PELVIS: A Foley catheter is seen within the bladder lumen. There\n is a blind-ending rectum. Dilated loops of small bowel are also seen within\n the pelvis. The free fluid is clearly identified within the pelvis.\n\n The osseous structures demonstrate degenerative changes of the spine as well\n as the hips. There is a mild lumbar scoliosis, concave to the right.\n\n IMPRESSION:\n (Over)\n\n 4:23 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: asses sbo\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Dilated loops of small bowel with an apparent stenosis just prior to the\n right lower quadrant stoma. No free intraperitoneal air.\n 2. Incompletely characterized but simple-appearing cysts in the liver and\n kidneys.\n\n Findings discussed with the surgical resident at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "O CHEST (SINGLE VIEW) IN O.R.", "row_id": 909511, "text": " 5:30 PM\n CHEST (SINGLE VIEW) IN O.R.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : ? PNEUMOTHORAX\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Evaluate for pneumothorax.\n\n COMPARISON: , 8:50 a.m.\n\n INTRAOPERATIVE SUPINE PORTABLE CHEST RADIOGRAPHS:\n\n Endotracheal tube is seen at the thoracic inlet. Nasogastric tube is\n extending into the proximal stomach. Right subclavian catheter tip is within\n the mid SVC. No definite evidence of pneumothorax. Again noted patchy\n opacities bilaterally appear slightly increased compared to earlier in day.\n These findings could represent aspiration. Heart size, mediastinal and hilar\n contours are unchanged. Osseous and soft tissue structures are stable.\n\n IMPRESSION:\n\n Slight interval increase in opacities bilaterally within the middle lung\n fields, which could represent aspiration in appropriate clinical context. No\n evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 909858, "text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man w/ resolving penumonia on last CXR \n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPHS.\n\n Right-sided subclavian line is seen with tip overlying the SVC. Cardiac,\n mediastinal, and hilar contours are unchanged. Pulmonary vascularity remains\n within normal limits. There has been interval improvement of the multifocal\n opacities consistent with improving pneumonia. New small bilateral pleural\n effusions are seen. There is also evidence of increased atelectasis at the\n left lung base.\n\n IMPRESSION: Improving pneumonia. New small bilateral pleural effusions and\n left basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 909520, "text": " 7:16 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -76 BY SAME PHYSICIAN\n : s/p right subclavian CVL placement - first film cut off apex\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with psbo and sagging o2 sats\n\n REASON FOR THIS EXAMINATION:\n s/p right subclavian CVL placement - first film cut off apex\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with partial small-bowel obstruction and sagging\n O2 sat. Status post right subclavian line placement. Initial films cut off\n at apex.\n\n COMPARISON: Two hours prior.\n\n Right subclavian line seen with the tip extending over the mid SVC. No\n evidence of pneumothorax. Heart size, mediastinal and hilar contour, lung\n volumes, lung parenchyma are unchanged. No definite evidence of pneumothorax.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2117-12-08 00:00:00.000", "description": "Report", "row_id": 1341108, "text": "NPN\nSee carevue for remarks and details:::\n\nFound unresponsive by family member on after being tired and sleepy all day. EMS called after family tried arouse pt by giving her milk (? family thought diabetic reaction)and coining w/ no response. Brought on the eve of , where CT of head showed left head bleed w/ shift. Pt transferred for further evaluation of bleed, prior transfer pt received Ativan and Pavulon hosp, dosages unknown. Pt arrived ICU this am around 0800. Since admission pt had head CT (in ED) which shows Left intraparychymal bleed ? secondary HTN and Left side shift. Prognosis poor per ICU and Neuromed team. Family meetings discuss prognosis and plan of care w/SW, Dr. and Dr.. Family still trying decide what do. Dr. and SW () meet w/ family again this eve try and finalize a decision about plan of care and code status of patient. NEOB involved, family no interest in donation of pts organs.\n\nNeuro: Not responding any stimuli. Pupils dilated, nonreactive, no corneal reflex. not moving any extremities, +babinski reflex. Dr. performed colonic test, w/no response. Checked tox screen make sure meds were not influencing any of the neuro findings, tox screen negative. apnea test negative, pt started overbreath vent. No other mid brain functions noted.\n\nCV: On dopa, HR ^ 120s, titrate dopa off and levo started. titrate MAP >60. SBP high 80s-90s. Received 1.6 liters of fluid try and control BP/HR w/ no effect.\n\nResp: Pt was on CMV until apnea trial, Now on SIMV 550x8, 5PS/5PEEP. Pt overbreathing vent by 5-6 breaths. right side lung clear thorughout, left side w/coarse-diminished breath sounds at bases. ? aspiration from family trying feed pt milk when at home when unconcious.\n\nGI: hypoactive BS, abd soft round nontender. NPO. needs frequent mouthcare, +odorous breath and old dried blood on tongue and in mouth.\n\nGU: Foley cath-urine clear, yellow, moderate amts secondary boluses.\n\nSkin/IV: aline and subclavian triple lumen placed upon arrival at . 2 PIV from OSH. small bruised area on right lower back, ? secondary coining that was performed on pt by family for arousal purposes before EMS was called.\n\nSocial: MULTIPLE family members have been at pts bedside today, including pts 3 children. Social work () involved, mulitple family meetings today decide plan of care/code status w/ family. Family still undecided. meet w/Dr. and this eve discuss family decisions made. Family aware of poor prognosis of pt.\n\nPlan: MAP >60, titrate levo/dopa as needed. Family mtgs as needed w/interdisciplinary team. Monitor Neuro status as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2117-12-09 00:00:00.000", "description": "Report", "row_id": 1341109, "text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: Pt's pupils are fixed and dilated. No spontaneous movements noted. Pt has been unresponsive nailbed and trap squeeze. Pt appears comfortable, no pain meds given.\n\nCV: SR. No ectopy. Levophed gtt titrated keep MAP > 60. CVP 0-1. Pt has NS @ 100cc hour infusing. Low grade temps. TMAX 100.8\n\nResp: No vent changes made. SIMV +PS 5peep 5 PS 40%FI02 RR10. LS have been clear. 02 sats 98-100% Pt suctioned few times for no sputum.\n\nGI/GU: Foley is patent and draining adequate amts of clear yellow urine. Absent BS.\n\nInteg: Skin is intact. Small reddened rash noted on left thigh where tape was removed.\n\nPlan: Continue with current plan of care. Offer emotional support family. Social services involved. ?CMO in the AM.\n" }, { "category": "Nursing/other", "chartdate": "2117-12-09 00:00:00.000", "description": "Report", "row_id": 1341110, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for no secretions.Temp 100.7. Getting Levophed. No weaning being done. Will cont monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2117-12-09 00:00:00.000", "description": "Report", "row_id": 1341111, "text": "NURSING NOTE:\nD/A: ON MORNING ROUNDS, DR. RECONFIRMED WITH STAFF PT FAMILY WISHES THAT WERE DISCUSSED AT A FAMILY MEETING LAST EVENING. PT BP WAS BE MAINTAINED MAP > 60 WITH LEVOPHED, RESP STATUS WOULD REMAIN ON SIMV UNTIL PT'S FAMILY WERE ABLE ARRIVE AGAIN TODAY. LEVOPHED WAS MINIMALLY TITRATED FOR GOAL MAP > 60, AND NO VENT CHANGES MADE. NEURO STATUS REMAINED UNCHANGED WITH PUPILS 6MM, NON REACTIVE, NO MOVEMENT WITH PAINFUL STIMULI, NO COUGH, NO GAG, NO CORNEAL REFLEX. OTHER TESTING PERFORMED BY NEUROLOGY. PT'S FAMILY ARRIVED IN THE AFTERNOON. FAMILY MEETING WAS HELD WITH DR. , MOREEN SOCIAL WORK, PT'S TWO DAUGHTERS, SON, AUNT AND NURSING PRESENT. DR. DISCUSSED PT'S CONDITION AND PROGNOSIS. PT'S FAMILY VERY CLEARLY VOICED THAT THEY WOULD LIKE LIFE SUPPORTING MEASURES BE STOPPED. FAMILY MEMBERS ASKED MANY QUESTIONS WHICH WERE ANSWERED BY DR. . AT FAMILY REQUEST, FAMILY VISITED WITH PT PRIOR STOPPING TREATMENT. THEN, PT WAS EXTUBATED, LEVOPHED STOPPED. FAMILY NOTIFIED AND MANY FAMILY MEMBERS REMAINED WITH PT UNTIL SHE EXPIRED. DR. PRONOUNCED PT AS TIME OF DEATH 1746. ONLY PT BELONGINGS WERE SOME MEDICATIONS FROM HOME WHICH FAMILY ASKED NURSING DISPOSE OF SAFELY. MEDS PLACED IN MEDICAL WASTE BIN. SMALL SILVER COLORED WAS LEFT IN PT'S HAND BY FAMILY, TAPED PT'S BODY BY NURSING. POST MORTEM CARE PERFORMED.\n" }, { "category": "Radiology", "chartdate": "2117-12-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 851952, "text": " 6:56 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: condition of ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with ICH\n REASON FOR THIS EXAMINATION:\n condition of ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT:\n\n CLINICAL INDICATION: This is a 54 y/o woman with mental status change and\n intracranial hemorrhage.\n\n TECHNIQUE: Axial 5 mm sections of the brain were obtained without IV\n contrast. There are no prior head CTs for comparison.\n\n FINDINGS: There is massive intraparenchymal hemorrhage involving the left\n basal ganglia. There is intraventricular extension into the left lateral\n ventricle and there is blood casting the left lateral ventricle, third\n ventricle, and fourth ventricle. There is a large amount of rightward shift\n of the normal midline structures. There is a small amount of blood layering\n in the occipital of the right lateral ventricle. The right lateral\n ventricle is dilated. The left lateral ventricle is completely effaced by the\n large intraparenchymal hemorrhage. The left basal ganglia intraparenchymal\n hemorrhage extends caudally through the posterior limb of the internal capsule\n into the pons. The sulcal subarachnoid spaces and basal cisterns are totally\n effaced.\n\n IMPRESSION:\n\n Large intraparenchymal hemorrhage in the left basal ganglia with\n intraventricular extension, massive shift of the midline brain structures \n the right side, and obstruction and dilation of the right lateral ventricle.\n\n This report was called emergently Dr. in the emergency\n room on at 9:00am.\n\n" }, { "category": "Radiology", "chartdate": "2117-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851953, "text": " 7:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ETT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with intubated for head bleed, ? Right mainstem intubation\n and aspiration.\n REASON FOR THIS EXAMINATION:\n evaluate for ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 54-year-old female status post intubation for an intracranial\n hemorrhage. Evaluate endotracheal tube placement.\n\n There are no prior studies available for comparison.\n\n SINGLE AP VIEW OF THE CHEST: An endotracheal tube is seen terminating\n approximately 1 cm superior the carina. Retraction via 1 cm is\n recommended. The cardiac, mediastinal, and hilar contours are normal. The\n aorta is slightly unfolded. The pulmonary vasculature is normal. There is\n minor atelectasis at the left lung base. Otherwise, bilateral lungs are\n clear, without evidence of infiltrates, effusions, or consolidations.\n Surrounding soft tissue and osseous structures are unremarkable.\n\n IMPRESSION:\n\n Endotracheal tube approximately 1 cm superior the carina. Retraction via 1\n cm is recommended. Mild left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852007, "text": " 11:27 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p subclavian placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with intubated for head bleed, ? Right mainstem intubation\n and aspiration.\n REASON FOR THIS EXAMINATION:\n s/p subclavian placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE:\n\n HISTORY: Question right main stem intubation and aspiration. The patient is\n also status post subclavian line placement.\n\n COMPARISON: Film performed at 7:00a the same day.\n\n Since the prior study a new right subclavian line has been inserted, the tip\n of which is in the proximal right atrium. There has been interval development\n of increased opacity with air bronchograms in the left lower lobe. In the\n proper clinical setting this would be consistent with aspiration. Tip of the\n endotracheal tube is 15 mm above the carina and could be pulled back if\n clinically indicated.\n\n IMPRESSION: Tubes and lines as described above.\n\n Interval worsening of left lower lobe opacity with air bronchograms suggestive\n of aspiration. Clinical correlation is advised.\n\n\n" }, { "category": "ECG", "chartdate": "2117-12-08 00:00:00.000", "description": "Report", "row_id": 190777, "text": "Sinus rhythm\nLeft ventricular hypertrophy\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 899683, "text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for cardiopulmonary process\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with T1DM with DKA\n REASON FOR THIS EXAMINATION:\n evaluate for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetic ketoacidosis, evaluate for any cardiopulmonary process.\n\n COMPARISON: None.\n\n AP CHEST RADIOGRAPH: The heart size is within normal limits. The mediastinal\n and hilar contours are normal. The pulmonary vascularity is normal in\n appearance. The lungs are clear without focal consolidations or effusions or\n pneumothorax.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-01-03 00:00:00.000", "description": "Report", "row_id": 1474436, "text": "Admission Note\nPt 23 y/o female who initially presented to EW on with c/o HA. LP performed, which was negative and CT Head (-). Pt sent home with percocet, but continued to have HA (? result of traumatic LP). Saturday night patient experiencing N/V and presented to EW on Sunday with BS 345, anion gap 40 in DKA. Patient given total 5L NS in EW and insulin gtt started. Morphine was given for HA with good effect and last given 2mg at 0700. Anzmet working well for episodes of nausea.\n\nCV: HR 110-120's, ST with no ectopy. NIBP 104-108/40's with MAP 60's. Patient received 40meq KCL PO and since has c/o nausea. Still needs additional 20meq KCL for total 60meq KCL...split doses to minimize GI upset.\n\nAccess: Pt arrived from EW with L AC 20g. Unable to obtain additional access despite multiple attempts by RN's, IV team and resident.\n\nResp: RR 14-20, sats 99-100% RA. BBS CTA.\n\nNeuro: Alert/oriented x3. Pleasant and cooperative with care. Denied pain initially, but then started to c/o HA (BS elevated at this time). Given 2mg morphine\n\nEndo: Pt arrived on 2units insulin gtt...BS 78. Pt had no additional access and after insulin being stopped for 20minutes, restarted with D5NS infusing wide open x2 liters. Patient also given 1/2amp D50 per resident/intern. Repeat BS 345 and recheck 307. Insulin gtt increased to 3units/hr. Repeat BS 415 and D5NS stopped after patient had received total 1.6L and switched to LR...insulin gtt increased to 5units/hr. Awaiting D5LR with 40meq KCL to come up from distribution.\n\nGI/GU: Abdomen soft, BS present. Tolerating small sips of water. Patient states that she voided few times in EW, but amount not recorded.\n\nSocial: Patient lives with sister. Sister was present in ER, but left to go home prior to transfer to MICU. Primary contact is listed as her father.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-03 00:00:00.000", "description": "Report", "row_id": 1474437, "text": "NPN 0700-1900\nEvents: Seen by Clinic, insulin adjustments made, to start on new insulin regimen with dinner tonight (clear liquids)- give glargine SC with SSI, turn insulin gtt off after 2hrs, obtain FBS q2hrs for first 6hrs to monitor for hyperglycemia then switch to achs fbs, adm SSI as ordered. Nutrition consult ordered.\n\nNeuro: Alert and Oriented x 3 presently, denies pain, no c/o nausea since 1600, pt states that she will attempt clear liquids for dinner, follows commands, asks appropriate questions.\n\nResp: Lungs CTA, RR 12-17 on RA, O2 sats 98-100%, no c/o SOB.\n\nCV: HR 81-109 NSR-ST, BP's 93-99/40-50's, no c/o CP, KCL and Mg repleted, to obtain labs at 2200, continue on D5NS at 150cc/hr, HO to reassess IVF after pt's dinner.\n\nEndo: FBS 76-380's, continues on Insulin gtt currently at 1.0 u/hr IV.\n\nGI: BS (+), no c/o abd. pain, to take clear liquids.\n\nGU: Foley cath intact draining clear yellow urine in adequate amts.\n\nSkin: Dry and Intact.\n\nPlan: Continue to obtain FBS q 1 while insulin gtt on, then follow FBS q 2hrs for 6hrs, then achs, continue SS as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-04 00:00:00.000", "description": "Report", "row_id": 1474438, "text": "Shift Note 1900-0700\nCV: HR 70-90's, NSR with no ectopy (occasionally slightly tachy). NIBP 90-120/40-60's. Patient's Mg 1.3 and 3gm IV Mag Sulfate ordered, but at that time unable to infuse d/t limited access. Pt given dose of Magnesium oxide 800mg. K 3.5 and given 40meq PO with 20meq to be given 4hrs after 40meq dose. Phos 0.6 and K Phos ordered. Once insulin gtt and maintenance d/c and new LEJ placed, Kphos and Mg administered. Repeat labs K4.3, Mg 2.2 and Phos 3.1 (Kphos not finished being infused when labs drawn).\n\nAccess: R AC 20g; LEJ placed by ultrasound by resident.\n\nResp: BBS CTA. RR 12-16, sats >99% RA.\n\nNeuro: A/O x3. Very pleasant and cooperative with care. c/o HA and given ibruprofen with good effect at 2100. Pt has been sleeping through most of night.\n\nGI/GU: Abdomen soft, BS present. Tolerating clear liquid diet. Foley draining light yellow urine, 160-450cc/hr. No BM this shift.\n\nEndo: Pt given 25units glarine with dinner ( beef broth, water and few sips of apple juice). Two hours later, at 2200 BS 172 and insulin gtt d/c along with D5NS maintenance fluids. BS rechecked hour later 161 and given 2units humalog coverage. BS continued to be checked Q2hours until 0200 and ranging 79-116. SSC initiated AC/HS. Pt seen by yesterday and needs to meet with nutrition.\n\nSocial: Sister to visit last evening. Patient talking on phone with family.\n" }, { "category": "Nursing/other", "chartdate": "2174-01-04 00:00:00.000", "description": "Report", "row_id": 1474439, "text": "NPN 0700-1900\nNeuro: A&Ox3, c/o HA when sitting up, gien ibuprofen x1 with good effect, following commands, communicating needs appropriately.\n\nResp: Lungs CTA, RR 16-20, O2 sats 99-100% on RA, no c/o SOB.\n\nCV: HR 80-105 SR-ST, no ectopy, BP's 90's-120's/50-60's, no edema, (+)pedal pulses.\n\nEndo: FBS 110-300, insulin dosage re-adjusted today by clinic.\n\nGI: BS (+), abd obese, soft, non-tender, no BM since adm., started on Docusate and Senna.\n\nGU: Foley cath dc'd intact, pt voiding in adequate amts without difficulty.\n\nSkin: Intact\n\nSocial: Sister visits in evenings.\n\nPlan: Transfer to floor when bed available. Transfer not written\n" }, { "category": "Nursing/other", "chartdate": "2174-01-05 00:00:00.000", "description": "Report", "row_id": 1474440, "text": "PT. REMAINS CALLED OUT TO FLOOR. REFER TO TRANSFER NOTE FOR FURTHER INFORMATION.\n\nPT. IS A/A/O AND C/O MILD HEADACHE. PT. TOOK IBUPROFEN 400MG PO THIS AM AT 0400, WITH SLIGHT RELIEF. OTHERWISE PT. IS NEUROLOGICAL INTACT. PT. V/S REMAIN WNL'S REFER TO CAREVUE FOR SPECIFICS. LUNGS ARE CLEAR AND RESP RATE CONTROLLED. O2 SATS >98% ABD. IS BENIGN IN ASSESSMENT WITH BOWEL SOUNDS EASILY AUDIBLE WITH NO STOOL NOTED THIS SHIFT. BLOOD SUGARS HAVE BEEN MUCH MORE CONTROLLED RANGING BETWEEN 91-99. I.V. ACCESS REMAINS INTACT, SECURED, AND FUNCTIONING WELL. SKIN REMAINS GROSSLY IN TACT. PT. IS A FULL CODE AND IS PRESENTLY CALLED OUT TO FLOOR. PT. HAS BEEN INQUIRING ABOUT POSSIBLE DISCHARGE WHICH SHE WILL ASK PHYSICIANS LATER TODAY.\n" } ]

[ { "category": "Echo", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 104820, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O cardiac surgery. Left ventricular function.\nHeight: (in) 64\nBP (mm Hg): 156/70\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 12:17\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 moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.\n\nLEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. There is mild regional left\nventricular systolic dysfunction. [Intrinsic left ventricular systolic\nfunction may be more depressed given the severity of valvular regurgitation.]\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; basal inferior -\nakinetic; mid inferior - akinetic; basal inferolateral - hypokinetic; mid\ninferolateral - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function is borderline normal. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\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. There is moderate thickening of the mitral valve\nchordae. Moderate to severe (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Severe\n[4+] tricuspid regurgitation is seen. There is severe pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. Significant pulmonic regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is moderate symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. There is mild to moderate regional left ventricular\nsystolic dysfunction (intrinsic systolic function may be more severely\ndepressed given magnitude of mitral regurgitation). Resting regional wall\nmotion abnormalities include inferior and inferolateral akinesis/hypokinesis.\n\nRight ventricular chamber size is normal. Right ventricular systolic function\nis borderline normal (intrinsic function may be depressed given magnitude of\ntricuspid regurgitation). There is abnormal septal motion/position consistent\nwith right ventricular pressure/volume overload. The ascending aorta is mildly\ndilated. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is moderate thickening of the mitral valve chordae.\nModerate to severe (3+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen.\nThere is severe pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 310621, "text": "Sinus rhythm, rate 76. Since the previous tracing the Q wave in lead III has\ndiminished. The deep T wave inversions in leads I, aVL and across the lateral\nprecordium persist.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2114-05-08 00:00:00.000", "description": "Report", "row_id": 310622, "text": "Sinus rhythm, rate 85. Since the previous tracing no changes have occurred.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2114-05-08 00:00:00.000", "description": "Report", "row_id": 310623, "text": "Sinus rhythm, rate 88. Diffuse ST-T wave abnormalities are seen. Small Q waves\nare present in the inferior leads. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2114-05-10 00:00:00.000", "description": "Report", "row_id": 1286373, "text": "NPN 7p-7a\n\n Pt. with four episodes of diarrhea, 2 episodes of nausea with vomitting. Remains off D10 and Insulin infusion with BS 72-207 overnoc with SSHI coverage. Started on zo-syn.\n\nReview of Systems-\n\n Pt. remains intact. Often, agitated and anxious. Sleeping in naps overnoc. Several c/o of epigastric pain, nausea and \"pills making me sick\". Pt. commented that famotidine makes him vomit...\n\nResp- Sat'ing 96-99% on 4L NC with occ dips when O2 not on as low as 72%. LS- crackles bibasilar (faint), diminished right base ? collapse vs. consolidation. No sputum production.\n\nCV- HR 70-85 NSR, no ectopy noted. Received 20meQ of KCL for K+ of 3.4 at 1600. Repeat K+ WNL. BP 140-150's overnoc. Lopressor changed to IV given nausea and vomitting. need to increase from 5mg to 10mg q 6. HCT/Hemoglobin stable at 29 and 9.0. SVO2 60's-70's%. Right foot remains cellulitic with dopplerable pulses.\n\n Pt. with diarrhea and vomitting overnoc. Requested anti-emetics/anti-nausea medication but then was sleeping shortly thereafter. Reported abd. pain X 1 overnoc self-resolving. Dr. allowing pt. to have crackers and clear liqs overnoc as pt. does not appear to be needing surgery.\n\n Pt. does not void. HD tom'row.\n\nEndo- Off insulin gtt. Off D10 as well. Receiving Humalog sliding scale.\n\nID- Now covered with zosyn, vanco, ceftriaxone for RLL cellulitis and acalculus cholecystitis... may add flagyl to coverage per notes. Need to send c.diff spec today.\n" }, { "category": "Nursing/other", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 1286369, "text": "Nsg Admit Note\n\n60 yo male admitted for sepsis protocol from ED.\n\nPMH includes IDDM, CAD with CABG ', CRF on dialysis - fistula to left arm, HTN, elevated cholesterol, GERD\n\nNKDA\n\nPt has an old ulcer to right foot big toe and has been going to PCP at hospital for followup. Pt developed epigastric pain - went to see PCP and after taking \"some medication\" he felt much worse and had N/V x2. PCP referred him here. Upon admit to - pt had elevated lactate, febrile, elevated WBC's and elevated BS. Started on sepsis protocol and transferred to MICU for further care.\n\nPt admitted to MICU via stretcher - transferred to bed without problem. has right IJ triple precep catheter and 2 heplocks to right arm. Left arm with fistula +bruit.\n\nCV - Afebrile. BP stable throughout the night. HR NSR - no ectopy.\nIVF - D51/2NS at 75/hr.\n\nResp - BS cl bilat. O2 at 4L via NC. No c/o SOB. Strong spont dry cough.\n\nGI - Abd large and distended. NPO except for ice chips. No nausea.\nPt passing sm amt loose stool frequently. Spec sent for cdiff. Attempted rectal bag - but it did not seal well. Now has mushroom cath in per patient's request. Guiac neg.\n\nGU - Pt is anuric. No foley. Pt normally gets dialysis on monday, wednesday and fridays. Plan is to dialyze this morning.\n\nSepsis - Lactate is down. Venous o2sat has ranged from 65-82%. Pt has been afebrile since admission.\n\nEndocrine - Pt recieved 10 units humulog in ED for BS 300's. BS has been 103-116 in the MICU. Insulin gtt started for anion gap but is only running at 1 u/hr.\n\nNeuro - Very pleasant and cooperative. Able to move very well and was able to get on and off the bedpan without problem. Prefers to lie on side - hates lying on his back. A&O x3. No c/o pain.\n\nSocial - Pt called wife and gave her an update on what was going on.\nShe has not contact us at all.\n\nA: Stable\n\nP: be call out to floor today if he continues doing well.\n" }, { "category": "Nursing/other", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 1286370, "text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--PT IS IRRITATED THAT HE CAN NOT EAT. MAE SPONT AND TO COMMAND. MOVES SELF IN BED. HE IS ALERT AND ORIENTED. SLIGHTLY AGITATED WITH DIALYSIS TODAY.\n\nCARDIAC--REMAINS HTN 170-180'S. RECIEVED PO ANTIHTN'S THIS AM. HR SR 80'S WITHOUT OBSERVED VEA. SVO2 62-69% WITH PRE- CATH.\n\n PT ON 4L NC AND REMOVED O2 TO CHECK ON R/A SAO2. WITH GOOD , PT'S SAO2 DECREASED TO 79. PLACED BACK ON O2 AT 4L NC. LUNGS WITH RHONCHI BILATERALLY. NON-PRODUCTIVE COUGH.\n\nGI--NPO EXCEPT FOR ICE CHIPS. PT TO HAVE ABD CT SCAN THIS AFTERNOON. HE IS STARTING PREP FOR THAT NOW 1430. STOOLING VIA MUSHROOM CATH. +BS.\n\nGU--ANURIC.\n\nENDO--ON INSULIN GTT PRESENTLY AT 3U HR WITH BS 97. ALSO RECEIVING D10 AT 50 CC HR FOR DKA.\n\nSKIN--R GREAT TOE IS NECROTIC WITH CELLULITIS APPEARING AROUND TOE. BUTTOCKS WITHOUT BREAKDOWN. R TRIPLE LUMEN IS OOZING SMALL AMTS OF BLOODY DRAINAGE.\n\nID--TO START ON PIPERCILLIN. OTHER ABX D/CED. AFEBRILE.\n\nPAIN--C/O TENDERNESS IN ABD. PT ALSO IS ANTSY IN WANTING TO GET UP WHILE HAVING DIALYSIS. NO PAIN MED GIVEN BUT PT .\n\nCOPING--FAMILY IN TO VISIT. THEY HAVE BEEN UPDATED ABOUT THE UPCOMING CT SCAN.\n\nA--? ABD PROCESS GOING ON. SLIGHTLY AGITATED.\n\nP--CON'T WITH CT PREP. CON'T TO MONITOR. CHECK BS. CHECK RESULTS OF 1400 LABS. OFFER SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 1286371, "text": "REsp.CAre Note: Attempted to star Patient on Non-invasive\nventilation. Patient has difficulty laying flat and is\nscheduled to go to Cat scan. He tolerated it for a short\ntime but then refused to wear it. Wearing 4L nasal O2.\n" }, { "category": "Nursing/other", "chartdate": "2114-05-09 00:00:00.000", "description": "Report", "row_id": 1286372, "text": "Nursing Progress Note 3pm-7pm\n\nNeuro: Patient extremely agitated, restless. Refusing to take prep for his abd ct, refusing multiple aspects of care.\n\nCV: Remained hypertensive 150-180 sys. Refused 6pm dose of metoprolol until after his ct scan, same given at 7pm. Bleeding from his fistulas post dialysis. Received ddavp and 1 unit of ffp.\n\nResp: Spontaneous desaturating to 78%, md's aware. CTA done while down in ct scan . nc 2-6 l/min .ABG drawn po2 60's, attempted to place patient on cpap but pt adamantly refused same.\n\nGI: Npo for scan. Rectal tube removed as patient began yelling and screaming that it was uncomfortable upon return from ct.\n\nGU:Anuric.\n\nEndo : Insulin titrated off, D10 off also md.\n\n RN\n\nOther: Aline attempted by md's but unsuccessful.\n" } ]

[ { "category": "Physician ", "chartdate": "2131-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353566, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 01:03 AM\n large amt ectopy, irregular supraventricular rhythm w/ new TWI in I,\n II, aVF and V4 while pt. asleep.\n Potassium repleted\n Was desatting on Bipap while asleep, RT increased Ipap and Epap and she\n responded well.\n Yelling in Farsi, per daughter this is normal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 05:46 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: 36.3\nC (97.3\n HR: 63 (50 - 79) bpm\n BP: 110/35(55) {90/28(45) - 126/74(84)} mmHg\n RR: 22 (17 - 26) insp/min\n SpO2: 86%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 743 mL\n 54 mL\n PO:\n 490 mL\n 30 mL\n TF:\n IVF:\n 253 mL\n 24 mL\n Blood products:\n Total out:\n 1,123 mL\n 173 mL\n Urine:\n 1,123 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n -380 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 86%\n ABG: ///45/\n Physical Examination\n A/Ox2\n HEENT: Tender in paraspinal muscles of neck, nontender scalp, No JVD\n Lungs: Crackles in L lung base>R, breathing comfortably\n Heart: RRR, II/VI systolic murmur\n Abd: Soft, NT, ND, BS+\n EXT: No peripheral edema\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 45 mEq/L\n 3.4 mEq/L\n 37 mg/dL\n 95 mEq/L\n 143 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n WBC\n 4.7\n 7.3\n Hct\n 30.2\n 27.3\n Plt\n 225\n 206\n Cr\n 1.2\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n Other labs: CK / CKMB / Troponin-T:29//<0.01, D-dimer:1023 ng/mL,\n Lactic Acid:0.8 mmol/L, Ca++:9.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: No objective e/o worsening, ABG is baseline, SPO2 also\n appears to be baseline. Pt. does not appear hypervolemic and is not\n having productive cough so doubt CHF or COPD exacerbation. Likely that\n her previous Bipap settings were inadequate.\n - Use new Bipap settings\n - Wean O2 to keep SPO2 between 88-92\n - Continue home meds\n .\n # Altered mental status/somnolence: Orientation at baseline. Appears\n much improved since stopping oxycodone.\n - Hold oxycodone\n .\n # Neck pain/Headache: Likely arthritis/nerve impingement. Responds\n well to tylenol\n - Neuro consult for pain management\n - Standing Tylenol\n - Consider NSAIDs but at risk for causing CHF exacerbation\n .\n #CAD: h/o CABG. Has been having\nHeart pain\n at home and taking\n nitro.\n - Consider outpt stress\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: Euvolemic as above.\n .\n # DMII: Required insulin drip o/n for BG >400 repeatedly. Now well\n under control after stopping steroids. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n ------ Protected Section ------\n Addendum:\n Called neurology for neck pain, management of possible neuropathic pain\n - suggest starting neurontin if suspicious for neuropathic pain.\n However suggest minimal dose of 300mg TID. If pt not sedated with that\n regimen may increase the following day to 600mg TID. Lyrica may be\n slightly less sedating but must be slowly titrated over weeks.\n - If neurotin proves too sedationg consider Lyrica or Trileptal.\n -Will start with small test dose of neurotinin, 100mg qhs to monitor\n for sedating effects.\n - If further questions with management will need to formally consult\n neuro.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:59 ------\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353471, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear - diminished at bilateral bases. RRR. Denies shortness of\n breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face mask of 80%.\n BIPAP placed overnight. O2 sats 97-100% Non-productive cough. Afebrile.\n Action:\n Given MDIs and nebs. Pt cont on Hi-flow FM- sating 92-98%%.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt sleepy but follows commands, Pupils equal and reactive, assists w/\n turns. Pt is Persian speaking- understands & speaks some English. Able\n to communicate her needs. C/o neck pain. ..pt w/ chronic neck pain. No\n s/s of seizure activity.\n Action:\n Given tyelenol q 6h & psych meds.\n Response:\n No change\n Plan:\n Cont to monitor MS closely, hold narcotics, cont w/ current psych\n regimen of psych meds.\n Hyperglycemia\n Assessment:\n Blood sugars 200s-400s. Whole blood glucose 430.\n Action:\n Started on insulin gtt. Prednisone d/c\n Response:\n Plan:\n Cont w/ hourly blood sugars, monitor labs.\n" }, { "category": "Respiratory ", "chartdate": "2131-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 353473, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 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: 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 is on Q6H Alb/Atro . Rx\ns were done by the RN.. Thank you.\n, RRT 17:00\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353470, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear - diminished at bilateral bases. RRR. Denies shortness of\n breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face mask of 80%.\n BIPAP placed overnight. O2 sats 97-100% Non-productive cough. Afebrile.\n Action:\n Given MDIs and nebs. Pt cont on Hi-flow FM- sating 92-98%%.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt sleepy but follows commands, Pupils equal and reactive, assists w/\n turns. Pt is Persian speaking- understands & speaks some English. Able\n to communicate her needs. C/o neck pain. ..pt w/ chronic neck pain. No\n s/s of seizure activity.\n Action:\n Given tyelenol q 6h & psych meds.\n Response:\n No change\n Plan:\n Cont to monitor MS closely, hold narcotics, cont w/ current psych\n regimen of psych meds.\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353552, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Pt was given 650mg tyelenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain, gabapentin ordered HS.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times and chanting\n w/ h/o schizophrenia, otherwise pleasant. Pt dozing on and off,\n following commands.\n Action:\n Cont w/ home regimine of psych meds and divalproex.\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353562, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times and chanting,\n otherwise pleasant & cooperative (h/o schizophrenia). Pt dozing on and\n off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid.\n Response:\n No change\n Plan:\n Cont to monitor MS closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 3L via NC w/ sats in low 90s\n Pt is on home O2\n of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time, bipap during any periods of sleep\n" }, { "category": "Physician ", "chartdate": "2131-12-28 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 353362, "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 72 yo women presents with worsening SOB, LE edema, neck pain. 3 days\n PTA she started called daughter more often and daughter noticed her\n sleeping upright. Visiting nurse on exam in increasing\n LE edema, so PCP increased lasix dose. daughter also noticed\n occasional confusion, especially when taking her oxycodone. In ED Temp\n 98.8, HR89, BP 102/65, Sat 86% on RA, RR25. ABG 7.37/78/62. Recent\n CO2s 70-80s. Has bipap at night prescribed, but has not been wearing\n it lately. Got Lasix and solumedrol in ED. Got lovenox for possible\n PE.\n Patient admitted from: ER\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 CAD\n CABG\n CHF, EF 40%, 1+ MR ()\n DM II\n COPD\n HTN\n schizophrenia with paranoia and hallucinations\n chronic neck pain with C2 nerve impingment, treated with ?oxycodone\n gets sleeping with oxycodone.\n L3 fracture in past\n h/o VT with ICD placed\n hypothyroid, DNI.\n Meds:\n Advair\n respiridone\n duoneb\n asa\n digoxin\n medroxyprogesterone\n glyburide\n levoxyl\n toprol XL\n abilify\n lasix\n zoloft\n depakote\n oxycodone\n CAD\n Occupation:\n Drugs: None\n Tobacco: 60 pack year tobacco\n Alcohol: None\n Other: Lives alone in , but patient can cook some of her\n food,and gets around house, daughter lives nearby.\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:15 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: 70 (69 - 70) bpm\n BP: 128/61(77) {128/61(77) - 128/61(77)} mmHg\n RR: 25 (15 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 180 mL\n Urine:\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 332 (332 - 332) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 18 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 4.1 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal, No(t) Distant)\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: Diminished: )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Trace, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed, moving extremeties, opens eyes to voice\n Labs / Radiology\n 209\n 31.8\n 291\n 1.2\n 30\n 43\n 91\n 3.4\n 142\n 6.4\n [image002.jpg]\n Fluid analysis / Other labs: BNP 497 ( better than most prior values)\n Imaging: CXR: No new infiltrate\n Assessment and Plan\n Acute on chronic respiratory failure: Severe hypoventilation likely\n due to COPD and maybe component of obesity. No evidence of heart\n failure/pulmonary edema on exam or\n CXR. PE is possible, but she has other likely diagnoses such as COPD\n exacerbation. Continue steroids, albuterol, atrovent, advair\n ALtered MS: Difficult to assess as she moves feet to touch and opens\n eyes. Will try narcan as she has been taking oxycodone frequently and\n has been known to make her somnolent.\n Chronic diastolic CHF: Might be too dry, so will hold lasix for a day.\n DM II: SSI insulin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 10:00 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-12-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 353363, "text": "Chief Complaint: Dyspnea\n HPI: Ms. is a 72 yo female with HTN, DM2, COPD, CHF EF 40%, CAD\n s/p cabg , schizophrenia who presents with SOB, orthopnea, LE edema,\n headache/neck pain and some confusion. History is obtained from her\n daughter. daughter lives close by to her mother. usually\n have lifeline to call her daughter. has been calling her\n daughter more frequently in the last few days with neck/head pain and\n the daughter decided to stay overnight during the last three days.\n Patient has chronic shortness of breath but complained more frequently\n in the last few days. She has been trying to sleep vertically in the\n last three days but her daughter does not know how her mother usually\n sleeps prior to this episode. Patient was slightly weak. Her lasix\n was increased to 120 mg from 80 mg 5 days ago by her primary care\n doctor for increased bilatral lower extremity edema and shortness of\n breath. Patient has chronic neck and head pain due to cervical DJD\n changes.\n Denies any fever, chills, nightsweats, chest pain, palpiations,\n abdominal pain, diarrhea, constipation, dysuria, hematuria, focal\n numbness, weakness.\n .\n In the ED vitals were T 98.8 HR 89 BP 102/55 RR 25 86% ? RA to 99%\n NRB 100%. ABG showed 7.37/78/62. Patient received solumedrol 125 IV\n once, furosemide 60 mg IV once and lovenox 80 mg IV once.\n .\n On arrival to the MICU patient was comfortable on BiPAP with vitals of\n T 98.4 HR 69 BP 128/61 RR 19 91% on FiO2 35% with 10/5. Patient was\n able to follow commands.\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 Risperdal 2 mg daily\n Atorvastatin 10 mg daily\n Advair 2 inh \n Tiotropium daily\n DuoNeb nebs \n ASA 81 mg daily\n Digoxin 125 mcg daily\n Medroxyprogesterone 10 mg daily\n Glyburide 5 mg daily\n Levothyroxine 125 mcg daily\n Phoslo 667 mg\n Metoprolol SR 25 mg daily\n Ablify 40 mg daily\n Furosemide 120 mg daily recently increased from 80mg on \n Zoloft 75 mg daily\n Depakote ER 500 mg daily\n Oxycodone 5 mg Q6H\n Past medical history:\n Family history:\n Social History:\n 1. CAD: s/p 4-vessel CABG \n 2. CHF: ECHO w/ 1+ MR, minimal AS, EF 40% w/ regional wall motion\n abnormalities\n 3. DM Type 2\n 4. HTN\n 5. COPD: on home O2 3.5L/m, BIPAP (settings 14/10) with multiple past\n admissions w/ pCO2 in the 70-80 range\n 6. Schizophrenia: initially symptomatic w/ paranoia and hallucinations,\n well controlled w/ meds\n 7. L3 fracture: \n 8. Symptomatic VT: s/p ICD in \n 9. Hypothyroidism\n mother died of MI at unknown age\n Lives alone in apartment; has home health aide\n daily; meals are prepared by the pt's daughter; walks independently but\n sometimes uses walker; uses home O2 and BiPAP at night; smoked 60\n pack-years but quit in ; no alcohol, IVDU, or cocaine use. Her\n daughter is lives near by and is involved in her care.:\n Review of systems:\n Flowsheet Data as of 12:49 AM\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: 60 (60 - 70) bpm\n BP: 119/53(69) {100/41(55) - 128/61(77)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 430 mL\n 0 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -430 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 579 (332 - 579) mL\n PS : 10 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: 7.40/75/76.//16\n Ve: 6.8 L/min\n PaO2 / FiO2: 217\n Physical Examination\n Vitals: T 98.4 HR 69 BP 128/61 RR 19 91% on FiO2 35% with 10/5.\n General: NAD, sleepy, opens eyes to verbal stimuli, Farsi-speaking\n only\n HEENT: NCAT, anicteric, chronic left sided droop per ED team who have\n taken care of her in the past, no injections, OP clear, MMM\n Neck: no LAD, supple, no jvd\n Heart: RRR no m/r/g\n Lungs: coarse diffuse inspiratory breath sounds on BiPAP, no \n or wheezes.\n Abd: mildly distended, +BS, NT, soft, no mass or organomegaly.\n Ext: trace edema\n Neuro: moving all extremities spontaneously, finger grip and plantar\n flexion bilaterally, normal muscle tone.\n Psych: sleepy but following commands, oriented to self and hospital,\n not date (baseline per daughter)\n Skin: no rashes\n / Radiology\n 232 mg/dL\n [image002.jpg]\n \n 2:33 A11/29/ 12:21 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 TC02\n 48\n Glucose\n 232\n Other : Lactic Acid:0.8 mmol/L\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: Most likely due to COPD exacerbation. Requires home oxygen\n and BiPAP but known not compliant with BiPAP. Pt was at her baseline\n CO2 on ABG. She was noted to often remove her BiPAP intermittently at\n night. Overmedication with oxycodone may play a role as well. Patient\n has known CHF with EF of 40%. CXR shows mild edema but not significant\n to explain her hypoxia. BNP 487 near baseline. PE will be on the\n differential but pt was unable to tolerate CTA. CXR with no evidence\n of infection. No leukocytosis. Received lovonex 125 mg IV once in\n ED. Unlikely to be ischemia without chest pain and without ischemic\n EKG changes.\n - BiPap\n - advair, tiotropium and albeterol\n - prednisone 60 mg daily, fast taper if patient improves\n - will hold on diuresis as exam and (increased BUN/Cr) are\n consistent with being intravascularly dry\n .\n # Altered mental status: Orientation at baseline. Likely hypercarbia\n in the setting of BiPAP non-compliance and multiple medications\n including oxycodone. No white count or fever to suggest infection.\n - will try a small dose of narcan\n - UA normal\n - UCx is pending\n .\n # Neck pain: Likely musculoskeletal vs. DJD changes. have nerve\n impingement in the C2 region based on her pain. Normal strenth.\n CT C spine done on as outpatient (ordered by PCP) which\n showed degenerative changes and limited study due to cervical\n positioning in lateral film. Pt cannot have MRI of her C spine\n due to her ICD.\n - ultram stopped in the past due to sleepiness.\n - tylenol around the clock\n - could consider lidoderm patch\n .\n #CAD: h/o CABG. No chest pain or EKG changes.\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: as above.\n .\n # DMII, controlled. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353546, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\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": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353530, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep and tolerating. Insulin gtt\n titrated off. Large amt of ectopy noted- sinus irregular, ? sm amt\n intermittent Afib, multi-focal PVC\ns, pacer setting on for SB 40\ns and\n noted V Pacing. EKG done. Cardiac enzymes sent and D Dimer sent to\n ROMI, R/O PE.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n FS off @ 0200 for rapidly declining FS -251 to 151 to 138-104 and off,\n dropping to 63 off but receiving Po repletion of Potassium and\n stabilizing @ 74\n Plan:\n Cont to monitor, oral in AM, heart healthy consistent carb diet\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n RT increased Ipap and Epap\n Response:\n Tolerating BiPAP MD to 0500\n Plan:\n BiPAP @ night, wean O2 as tolerated off BiPAP< pt COPD on home O2\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital, PEERLA, able to guesture to head and state\npain\n Action:\n Reoriented via daughter\n Response:\n acute change, shouting in AM but able to point to head and state\npain\n, per daughter will shout @ basline and not familiar with\ndates\n Plan:\n Cont to monitor, Farsi translator, re-orient frequently\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Acute on chronic pain, daughter translating, neck pain and headache, pt\n shouting\npain\n and pointing to head\n Action:\n 1mg Acetaminophen, @ , and 0600, Lidocaine patch to neck, heat\n packs to neck\n Response:\n Able to sleep throughout most of night\n Plan:\n Ask Q6hrs if needs Acetaminophen, Lidocaine patch, heat packs ? further\n pain control\n" }, { "category": "Physician ", "chartdate": "2131-12-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 353540, "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 EKG - At 01:03 AM\n large amt ectopy\n -BIPAP titrated up with resultant improvement in SaO2 to 93% during\n sleep\n -Increased ectopy across the night and with bradycardia to 40 with\n pacer started.\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) - 04:00 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 Flowsheet Data as of 09:37 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: 66 (50 - 79) bpm\n BP: 106/77(84) {90/28(45) - 126/77(84)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 743 mL\n 554 mL\n PO:\n 490 mL\n 530 mL\n TF:\n IVF:\n 253 mL\n 24 mL\n Blood products:\n Total out:\n 1,123 mL\n 318 mL\n Urine:\n 1,123 mL\n 318 mL\n NG:\n Stool:\n Drains:\n Balance:\n -380 mL\n 236 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///45/\n Physical Examination\n General Appearance: Overweight / Obese\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: Crackles : Left > Right, Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed, Examination in\n English\npatient able to lift LE bilaterally with equal strength and\n upper extremities with equal strength\nno evidence of CN abnormalities\n on exam\n Labs / Radiology\n 9.5 g/dL\n 206 K/uL\n 115 mg/dL\n 1.1 mg/dL\n 45 mEq/L\n 4.3 mEq/L\n 37 mg/dL\n 95 mEq/L\n 143 mEq/L\n 29.5 %\n 7.3 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n WBC\n 4.7\n 7.3\n Hct\n 30.2\n 27.3\n 29.5\n Plt\n 225\n 206\n Cr\n 1.2\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n Other labs: CK / CKMB / Troponin-T:29//<0.01, D-dimer:1023 ng/mL,\n Lactic Acid:0.8 mmol/L, Ca++:9.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n ECG: Ectopic atrial rhythm noted\n Assessment and Plan\n 72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Ovenright patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n 1)Respiratory Failure-\n -Advair/Spiriva\n -Will up-titrate BIPAP to 16/12 for use with 4 lpm O2\n -This is in the setting of empiric titration of BIPAP in ICU with\n oxygen saturations stabilized at 93% during brief period of sleep last\n night.\n -Would continue with BIPAP during any period of sleep\n -Steroids D/C\nd without consequence\n -Follow up with sleep clinic and outpatient sleep study to truly\n optimize treatment over long term\n -Would favor full PFT\ns and lung volumes in follow up given poor\n patient effort and suggestion of restrictive ventilatory defect.\n 2)Congestive Heart Failure-This is with reasonable stability on recent\n ECHO and has AICD placed at this time with pacer capacity.\n -Digoxin\n -ASA\n -ECG without significant changes\n -Continue with telemetry while on floor\n -\n 3)Neck Pain-\n -Lidocaine patch\n -Tylenol to continue\n -Neuro consult to evaluate for strategies for management.\n -Consider soft collar in addition to neurontin\n .H/O PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACUTE PAIN\n HYPERGLYCEMIA\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition :ICU\nconsider transfer to floor with continued stability\n and stable BIPAP settings.\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2131-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353543, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 01:03 AM\n large amt ectopy, irregular supraventricular rhythm w/ new TWI in I,\n II, aVF and V4 while pt. asleep.\n Potassium repleted\n Was desatting on Bipap while asleep, RT increased Ipap and Epap and she\n responded well.\n Yelling in Farsi, per daughter this is normal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 05:46 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: 36.3\nC (97.3\n HR: 63 (50 - 79) bpm\n BP: 110/35(55) {90/28(45) - 126/74(84)} mmHg\n RR: 22 (17 - 26) insp/min\n SpO2: 86%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 743 mL\n 54 mL\n PO:\n 490 mL\n 30 mL\n TF:\n IVF:\n 253 mL\n 24 mL\n Blood products:\n Total out:\n 1,123 mL\n 173 mL\n Urine:\n 1,123 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n -380 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 86%\n ABG: ///45/\n Physical Examination\n A/Ox2\n HEENT: Tender in paraspinal muscles of neck, nontender scalp, No JVD\n Lungs: Crackles in L lung base>R, breathing comfortably\n Heart: RRR, II/VI systolic murmur\n Abd: Soft, NT, ND, BS+\n EXT: No peripheral edema\n Labs / Radiology\n 206 K/uL\n 9.5 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 45 mEq/L\n 3.4 mEq/L\n 37 mg/dL\n 95 mEq/L\n 143 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n WBC\n 4.7\n 7.3\n Hct\n 30.2\n 27.3\n Plt\n 225\n 206\n Cr\n 1.2\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n Other labs: CK / CKMB / Troponin-T:29//<0.01, D-dimer:1023 ng/mL,\n Lactic Acid:0.8 mmol/L, Ca++:9.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: No objective e/o worsening, ABG is baseline, SPO2 also\n appears to be baseline. Pt. does not appear hypervolemic and is not\n having productive cough so doubt CHF or COPD exacerbation. Likely that\n her previous Bipap settings were inadequate.\n - Use new Bipap settings\n - Wean O2 to keep SPO2 between 88-92\n - Continue home meds\n .\n # Altered mental status/somnolence: Orientation at baseline. Appears\n much improved since stopping oxycodone.\n - Hold oxycodone\n .\n # Neck pain/Headache: Likely arthritis/nerve impingement. Responds\n well to tylenol\n - Neuro consult for pain management\n - Standing Tylenol\n - Consider NSAIDs but at risk for causing CHF exacerbation\n .\n #CAD: h/o CABG. Has been having\nHeart pain\n at home and taking\n nitro.\n - Consider outpt stress\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: Euvolemic as above.\n .\n # DMII: Required insulin drip o/n for BG >400 repeatedly. Now well\n under control after stopping steroids. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n" }, { "category": "Physician ", "chartdate": "2131-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353641, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n -Continued neck and head pain throughout day, agitation\n - Started Ibuprofen TID, neurotin, zyprexa\n -Increased ISS\n -Given PO lasix 20mg x1 for desat\n -pt repeatally desat to mid 80s throughout day and night (moaning /\n singing throughout).\n - On bipap overnight titrating dose, pt repeatally breaks seal of bipap\n with hand and desats\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 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 06:18 AM\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: 36.7\nC (98.1\n HR: 60 (49 - 74) bpm\n BP: 122/45(65) {92/25(46) - 127/77(84)} mmHg\n RR: 24 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,094 mL\n PO:\n 1,070 mL\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 1,363 mL\n 210 mL\n Urine:\n 1,363 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 100%\n ABG: ///42/\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 191 K/uL\n 10.2 g/dL\n 77 mg/dL\n 1.1 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 96 mEq/L\n 142 mEq/L\n 29.6 %\n 8.1 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n 04:00 AM\n WBC\n 4.7\n 7.3\n 8.1\n Hct\n 30.2\n 27.3\n 29.5\n 29.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n 77\n Other labs: PT / PTT / INR:12.3/23.1/1.0, CK / CKMB /\n Troponin-T:29//<0.01, D-dimer:1023 ng/mL, Lactic Acid:0.8 mmol/L,\n Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353643, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n -Continued neck and head pain throughout day, agitation\n - Started Ibuprofen TID, neurotin, zyprexa\n -Increased ISS\n -Given PO lasix 20mg x1 for desat\n -pt repeatally desat to mid 80s throughout day and night (moaning /\n singing throughout).\n - On bipap overnight titrating dose, pt repeatally breaks seal of bipap\n with hand and desats\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 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 06:18 AM\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: 36.7\nC (98.1\n HR: 60 (49 - 74) bpm\n BP: 122/45(65) {92/25(46) - 127/77(84)} mmHg\n RR: 24 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,094 mL\n PO:\n 1,070 mL\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 1,363 mL\n 210 mL\n Urine:\n 1,363 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 100%\n ABG: ///42/\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 191 K/uL\n 10.2 g/dL\n 77 mg/dL\n 1.1 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 96 mEq/L\n 142 mEq/L\n 29.6 %\n 8.1 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n 04:00 AM\n WBC\n 4.7\n 7.3\n 8.1\n Hct\n 30.2\n 27.3\n 29.5\n 29.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n 77\n Other labs: PT / PTT / INR:12.3/23.1/1.0, CK / CKMB /\n Troponin-T:29//<0.01, D-dimer:1023 ng/mL, Lactic Acid:0.8 mmol/L,\n Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: No objective e/o worsening, ABG is baseline, SPO2 also\n appears to be baseline. Pt. does not appear hypervolemic and is not\n having productive cough so doubt CHF or COPD exacerbation. Likely that\n her previous Bipap settings were inadequate.\n - Use new Bipap settings\n - Wean O2 to keep SPO2 between 88-92\n - Continue home meds\n .\n # Altered mental status/somnolence: Orientation at baseline. Appears\n much improved since stopping oxycodone.\n - Hold oxycodone\n .\n # Neck pain/Headache: Likely arthritis/nerve impingement. Responds\n well to tylenol\n - Neuro consult for pain management\n - Standing Tylenol\n - Consider NSAIDs but at risk for causing CHF exacerbation\n .\n #CAD: h/o CABG. Has been having\nHeart pain\n at home and taking\n nitro.\n - Consider outpt stress\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: Euvolemic as above.\n .\n # DMII: Required insulin drip o/n for BG >400 repeatedly. Now well\n under control after stopping steroids. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n Addendum:\n Called neurology for neck pain, management of possible neuropathic pain\n - suggest starting neurontin if suspicious for neuropathic pain.\n However suggest minimal dose of 300mg TID. If pt not sedated with that\n regimen may increase the following day to 600mg TID. Lyrica may be\n slightly less sedating but must be slowly titrated over weeks.\n - If neurotin proves too sedationg consider Lyrica or Trileptal.\n -Will start with small test dose of neurotinin, 100mg qhs to monitor\n for sedating effects.\n - If further questions with management will need to formally consult\n neuro.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353644, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n -Continued neck and head pain throughout day, agitation\n - Started Ibuprofen TID, neurotin, zyprexa\n -Increased ISS\n -Given PO lasix 20mg x1 for desat\n -pt repeatally desat to mid 80s throughout day and night (moaning /\n singing throughout).\n - On bipap overnight titrating dose, pt repeatally breaks seal of bipap\n with hand and desats\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 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 06:18 AM\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: 36.7\nC (98.1\n HR: 60 (49 - 74) bpm\n BP: 122/45(65) {92/25(46) - 127/77(84)} mmHg\n RR: 24 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,094 mL\n PO:\n 1,070 mL\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 1,363 mL\n 210 mL\n Urine:\n 1,363 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 100%\n ABG: ///42/\n Physical Examination\n A/Ox2\n HEENT: Tender in paraspinal muscles of neck, nontender scalp, No JVD\n Lungs: Crackles in L lung base>R, breathing comfortably\n Heart: RRR, II/VI systolic murmur\n Abd: Soft, NT, ND, BS+\n EXT: No peripheral edema\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 191 K/uL\n 10.2 g/dL\n 77 mg/dL\n 1.1 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 96 mEq/L\n 142 mEq/L\n 29.6 %\n 8.1 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n 04:00 AM\n WBC\n 4.7\n 7.3\n 8.1\n Hct\n 30.2\n 27.3\n 29.5\n 29.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n 77\n Other labs: PT / PTT / INR:12.3/23.1/1.0, CK / CKMB /\n Troponin-T:29//<0.01, D-dimer:1023 ng/mL, Lactic Acid:0.8 mmol/L,\n Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: No objective e/o worsening, ABG is baseline, SPO2 also\n appears to be baseline. Pt. does not appear hypervolemic and is not\n having productive cough so doubt CHF or COPD exacerbation. Likely that\n her previous Bipap settings were inadequate.\n - Use new Bipap settings\n - Wean O2 to keep SPO2 between 88-92\n - Continue home meds\n .\n # Altered mental status/somnolence: Orientation at baseline. Appears\n much improved since stopping oxycodone.\n - Hold oxycodone\n .\n # Neck pain/Headache: Likely arthritis/nerve impingement. Responds\n well to tylenol\n - Neuro consult for pain management\n - Standing Tylenol\n - Consider NSAIDs but at risk for causing CHF exacerbation\n .\n #CAD: h/o CABG. Has been having\nHeart pain\n at home and taking\n nitro.\n - Consider outpt stress\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: Euvolemic as above.\n .\n # DMII: Required insulin drip o/n for BG >400 repeatedly. Now well\n under control after stopping steroids. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n Addendum:\n Called neurology for neck pain, management of possible neuropathic pain\n - suggest starting neurontin if suspicious for neuropathic pain.\n However suggest minimal dose of 300mg TID. If pt not sedated with that\n regimen may increase the following day to 600mg TID. Lyrica may be\n slightly less sedating but must be slowly titrated over weeks.\n - If neurotin proves too sedationg consider Lyrica or Trileptal.\n -Will start with small test dose of neurotinin, 100mg qhs to monitor\n for sedating effects.\n - If further questions with management will need to formally consult\n neuro.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353436, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout- diminished at bilateral bases. RRR. Denies\n shortness of breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face\n mask of 80%. BIPAP placed overnight. O2 sats 97-100% Non-productive\n cough. Afebrile.\n Action:\n Given alb/atrovent nebs, advair . Pt currently on 50% Hi-flow FM-\n sating 98%. Placed on NC of 5-6L when eating.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt sleepy but follows commands, Pupils equal and reactive, assists w/\n turns. Pt is Persian speaking- understands & speaks some English. Able\n to communicate her needs. C/o neck pain. ..pt w/ chronic neck pain. No\n s/s of seizure activity.\n Action:\n Given tyelenol q 6h & psych meds.\n Response:\n No change\n Plan:\n Cont to monitor MS closely, hold narcotics, cont w/ current psych\n regimen of psych meds.\n" }, { "category": "Physician ", "chartdate": "2131-12-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 353422, "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 NON-INVASIVE VENTILATION - START 09:59 PM\n -Narcan given with some improvement in respiratory status\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 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: Dyspnea\n Flowsheet Data as of 09:11 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: 36.6\nC (97.9\n HR: 78 (59 - 79) bpm\n BP: 99/59(69) {99/36(49) - 128/86(91)} mmHg\n RR: 25 (15 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 44 mL\n PO:\n TF:\n IVF:\n 44 mL\n Blood products:\n Total out:\n 380 mL\n 470 mL\n Urine:\n 380 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -380 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 579 (332 - 579) mL\n PS : 10 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: 7.40/75/76./47/16\n Ve: 6.8 L/min\n PaO2 / FiO2: 95\n Physical Examination\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), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): Place, Person, Movement: Not assessed, Tone: Not\n assessed, Improved altertness this morning, reasonable maintenance of\n interactiveness with prompting\n Labs / Radiology\n 10.3 g/dL\n 225 K/uL\n 201 mg/dL\n 1.2 mg/dL\n 47 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 94 mEq/L\n 145 mEq/L\n 30.2 %\n 4.7 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n WBC\n 4.7\n Hct\n 30.2\n Plt\n 225\n Cr\n 1.2\n TCO2\n 48\n Glucose\n 232\n 201\n Other labs: Lactic Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirementfor BIPAP in\n the setting of known obstructive lung disease and narcotic use for next\n pain. She has a profound elevation of HCO3-suggesting signficant\n chronic compromise of ventilation. She in response to intervention has\n had improvement in alertness and responsiveness. Initial ABG was\n 7.40/75/76 which represents signficiant combination of respiratory\n acidosis and metabolic alkalosis.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)--At this time her exam does\n not appear to be one of severe volume overload based upon exam at this\n time--with minimal peripheral edema despite some modest suggestion of\n pulmonary edema on initial CXR. We do not have a story of acute change\n over time and do not have a clear picture of fever/phlegm arguing for\n pneumonia, she has no evidence of acute congestive heart failure, she\n has background combined obstructive and restrictive ventilatory defect\n which is likely at play.\n -Pred 60mg/d-->Will D/C with PCO2 at baseline, decreased lungs with\n good air movement.\n -Albuterol/Atrovent\n -Advair continuing\n -Titatropium\n -WIll hold further diuresis\n -Return to O2 and BIPAP as at baseline\n -Congestive Heart Failure-\n -Continue with B-blocker\n -Return to baseline diuretic dosing\n ALTERED MENTAL STATUS (NOT DELIRIUM)--Likely a combination of chronic\n hypercarbia, new metabolic alkalosis and narcotic dosing for pain.\n This is in the setting of background schizophrenia.\n -Hold Narcotics\n -Zoloft\n -Dilantin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353430, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rhonchorous throughout- diminished at bilateral bases. RRR. Denies\n shortness of breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face\n mask of 80%. BIPAP placed overnight. O2 sats 97-100% Non-productive\n cough. Afebrile.\n Action:\n Given alb/atrovent nebs, advair . Pt currently on 50% Hi-flow FM-\n sating 98%. Placed on NC of 5-6L when eating.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-12-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353438, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:59 PM\n Received 0.2 mg Narcan overnight as a trial.\n Allergies:\n No Known Drug Allergies\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 05:49 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: 68 (60 - 77) bpm\n BP: 105/86(91) {100/37(52) - 128/86(91)} mmHg\n RR: 25 (15 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 430 mL\n 250 mL\n Urine:\n 430 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -430 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 579 (332 - 579) mL\n PS : 10 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 17 cmH2O\n SpO2: 96%\n ABG: 7.40/75/76./47/16\n Ve: 6.8 L/min\n PaO2 / FiO2: 217\n Physical Examination\n General: NAD, sleepy, opens eyes to verbal stimuli, Farsi-speaking\n only\n HEENT: NCAT, anicteric, chronic left sided droop per ED team who have\n taken care of her in the past, no injections, OP clear, MMM\n Neck: no LAD, supple, no jvd\n Heart: RRR no m/r/g\n Lungs: coarse diffuse inspiratory breath sounds on nasal canula, no\n crackles or wheezes.\n Abd: mildly distended, +BS, NT, soft, no mass or organomegaly.\n Ext: trace edema\n Neuro: moving all extremities spontaneously, finger grip and plantar\n flexion bilaterally, normal muscle tone.\n Psych: sleepy but following commands, oriented to self and hospital,\n not date (baseline per daughter)\n Skin: no rashes\n / Radiology\n 225 K/uL\n 10.3 g/dL\n 201 mg/dL\n 1.2 mg/dL\n 47 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 94 mEq/L\n 145 mEq/L\n 30.2 %\n 4.7 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n WBC\n 4.7\n Hct\n 30.2\n Plt\n 225\n Cr\n 1.2\n TCO2\n 48\n Glucose\n 232\n 201\n Other : Lactic Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: Patient\ns admission ABG with pCO2 at patient\ns baseline, but\n normal pH, indicating a superimposing metabolic alkalosis on top of and\n opposing chronic CO2 retension/respiratory acidosis. Metabolic\n alkalosis likely secondary to increased Lasix and contraction\n alkalosis. Her dyspnea is likely a combination of chronic ventillatory\n failure and contraction alkalosis.\n No evidence for CHF (BNP 487), pneumonia (CXR without infiltrates), PE,\n or cardiac ischemia (EKG unchanged).\n - cont. BiPap\n - cont. home doses of advair, tiotropium and albeterol\n - stop prednisone, unlikely to be a COPD exacerbation.\n - hold diuresis as exam and (increased BUN/Cr) are consistent with\n being intravascularly dry\n .\n # Altered mental status/somnolence: Orientation at baseline. Increased\n somnolence likely related to metabolic abnormalities, hypercarbia in\n the setting of BiPAP non-compliance, and multiple medications including\n oxycodone. No white count or fever to suggest infection.\n - avoid opiates\n - use BiPAP at night\n - f/u UCx\n - f/u MS exam\n .\n # Neck pain: Likely musculoskeletal vs. DJD changes. have nerve\n impingement in the C2 region based on her pain. Normal strength. CT C\n spine done on as outpatient (ordered by PCP) which showed\n degenerative changes and limited study due to cervical positioning in\n lateral film. Pt cannot have MRI of her C spine due to her ICD.\n - ultram stopped in the past due to sleepiness.\n - avoiding narcotics per above.\n - tylenol around the clock\n - will consider lidoderm patch\n .\n #CAD: h/o CABG. No chest pain or EKG changes.\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: as above.\n .\n # DMII, controlled. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353522, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep and tolerating. Insulin gtt\n titrated off. Large amt of ectopy noted- sinus irregular, ? sm amt\n intermittent Afib, multi-focal PVC\ns, pacer setting on for SB 40\ns and\n noted V Pacing. EKG done. Cardiac enzymes sent and D Dimer sent to\n ROMI, R/O PE.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n FS off @ 0200 for rapidly declining FS -251 to 151 to 138-104 and off,\n dropping to 63 off but receiving Po repletion of Potassium and\n stabilizing @ 74\n Plan:\n Cont to monitor, oral in AM, heart healthy consistent carb diet\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n RT increased Ipap and Epap\n Response:\n Tolerating BiPAP MD to 0500\n Plan:\n BiPAP @ night, wean O2 as tolerated off BiPAP< pt COPD on home O2\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital, PEERLA, able to guesture to head and state\npain\n Action:\n Reoriented via daughter\n Response:\n acute change, shouting in AM but able to point to head and state\npain\n, per daughter will shout @ basline and not familiar with\ndates\n Plan:\n Cont to monitor, Farsi translator, re-orient frequently\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Acute on chronic pain, daughter translating, neck pain and headache, pt\n shouting\npain\n and pointing to head\n Action:\n 1mg Acetaminophen, @ , and 0600, Lidocaine patch to neck, heat\n packs to neck\n Response:\n Able to sleep throughout most of night\n Plan:\n Ask Q6hrs if needs Acetaminophen, Lidocaine patch, heat packs ? further\n pain control\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353409, "text": "72 yo woman who presented to the ED with worsening SOB, LE edema, and\n neck pain. 3 days PTA she started called daughter more often and\n daughter noticed her sleeping upright. Visiting nurse \n on exam in increasing LE edema, so PCP increased lasix dose. daughter\n also noticed occasional confusion, especially when taking her\n oxycodone. In ED Temp 98.8, HR89, BP 102/65, Sat 86% on RA, RR25. ABG\n 7.37/78/62. Recent CO2s 70-80s. Has bipap at night prescribed, but\n has not been wearing it lately. Got Lasix and solumedrol in ED. Got\n lovenox for possible PE.\n Pt was on BiPap upon arrival to the MICU, w/ 02 sat\ns in the mid 90%\n pt more awake after arrival in the MICU, pulling at BiPap mask,\n desatting immediately when mask off, ABG done, 7.40/75/76, Bipap\n removed and pt now on HiFlo 02 mask 80%, w/ 02 sats in the mid to high\n 90%\ns. pt more compliant w/ mask. Agitated at times, speaks little\n English but per daughter understands .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived on Bipap 35% 10/5, att to pull off mask at times, ABG\n 7.40/75/76 02 sats in the low-mid 90%\ns, quickly desatting when mask\n off.\n Action:\n BiPap removed, pt placed on hi Flow 02 mask 80%, lasix was given in the\n ED for ?CHF, also given solumedrol in the ED and now started on\n prednisone.\n Response:\n Tol better, 02 sat\ns now in the mid- high 90%\ns UOP 60-100ml/hr.\n Plan:\n Cont hi 02, Bipap as needed, prednisone taper. Hold off on further\n diuresis as BNP near baseline and BUN/Cr elevated.\n Altered mental status (not Delirium)\n Assessment:\n Assessment limited r/t language barrier, however upon arrival pt att to\n remove Bipap mask, agitated at times moaning calling out in native\n language (pt is Persian and speaks Farsi) , able to make needs known\n and answer y/n ?\ns, but ? orientation.\n Action:\n Bipap removed as Pco2 only slightly improved, pt given PO liquids per\n pt req.\n Response:\n Pt settled out after needs met, sleeping at this time, when calm pt is\n able to speak limited English to make needs known.\n Plan:\n Cont to monitor PCo2, daughter will be in this am to help translate for\n pt.\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353517, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep and tolerating. Insulin gtt\n titrated off. Large amt of ectopy noted- sinus irregular, ? sm amt\n intermittent Afib, multi-focal PVC\ns, pacer setting on for SB 40\ns and\n noted V Pacing. EKG done. Cardiac enzymes sent and D Dimer sent to\n ROMI, R/O PE.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n FS off @ 0200 for rapidly declining FS -251 to 151 to 138-104 and off,\n dropping to 63 off but receiving Po repletion of Potassium and\n stabilizing @ 74\n Plan:\n Cont to monitor, oral in AM, heart healthy consistent carb diet\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n RT increased Ipap and Epap\n Response:\n Tolerating BiPAP MD to 0500\n Plan:\n BiPAP @ night, wean O2 as tolerated off BiPAP< pt COPD on home O2\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital, PEERLA, able to guesture to head and state\npain\n Action:\n Reoriented via daughter\n Response:\n acute change, shouting in AM but able to point to head and state\npain\n, per daughter will shout @ basline and not familiar with\ndates\n Plan:\n Cont to monitor, Farsi translator, re-orient frequently\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353520, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep and tolerating. Insulin gtt\n titrated off. Large amt of ectopy noted- sinus irregular, ? sm amt\n intermittent Afib, multi-focal PVC\ns, pacer setting on for SB 40\ns and\n noted V Pacing. EKG done. Cardiac enzymes sent and D Dimer sent to\n ROMI, R/O PE.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n FS off @ 0200 for rapidly declining FS -251 to 151 to 138-104 and off,\n dropping to 63 off but receiving Po repletion of Potassium and\n stabilizing @ 74\n Plan:\n Cont to monitor, oral in AM, heart healthy consistent carb diet\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n RT increased Ipap and Epap\n Response:\n Tolerating BiPAP MD to 0500\n Plan:\n BiPAP @ night, wean O2 as tolerated off BiPAP< pt COPD on home O2\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital, PEERLA, able to guesture to head and state\npain\n Action:\n Reoriented via daughter\n Response:\n acute change, shouting in AM but able to point to head and state\npain\n, per daughter will shout @ basline and not familiar with\ndates\n Plan:\n Cont to monitor, Farsi translator, re-orient frequently\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353628, "text": "Events: Agitated on arrival- HA throughout most of day. Meeting w/\n daughter, RN and MD for plan for pain control. Called in and plan for\n monitoring on BiPAP overnight in MICU ? C/O in AM. Given SL ,\n scheduled medications, additional Motrin and able to tolerate BiPAP\n overnight. ? new BiPAP needs- cont to be low to mid 80\ns to low 90\ns on\n new BiPAP levels. Desat to 78% w/ sleep apnea if off BiPAP. Low MAP 88-\n to low 50\ns while asleep.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self but per\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353406, "text": "72 yo woman who presented to the ED with worsening SOB, LE edema, and\n neck pain. 3 days PTA she started called daughter more often and\n daughter noticed her sleeping upright. Visiting nurse \n on exam in increasing LE edema, so PCP increased lasix dose. daughter\n also noticed occasional confusion, especially when taking her\n oxycodone. In ED Temp 98.8, HR89, BP 102/65, Sat 86% on RA, RR25. ABG\n 7.37/78/62. Recent CO2s 70-80s. Has bipap at night prescribed, but\n has not been wearing it lately. Got Lasix and solumedrol in ED. Got\n lovenox for possible PE.\n Pt was on BiPap upon arrival to the MICU, w/ 02 sat\ns in the mid 90%\n pt more awake after arrival in the MICU, pulling at BiPap mask,\n desatting immediately when mask off, ABG done, 7.40/75/76, Bipap\n removed and pt now on HiFlo 02 mask 80%, w/ 02 sats in the mid to high\n 90%\ns. pt more compliant w/ mask. Agitated at times, speaks little\n English but per daughter understands .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived on Bipap 35% 10/5, att to pull off mask at times, ABG\n 7.40/75/76 02 sats in the low-mid 90%\ns, quickly desatting when mask\n off.\n Action:\n BiPap removed, pt placed on hi Flow 02 mask 80%, lasix was given in the\n ED for ?CHF\n Response:\n Tol better, 02 sat\ns now in the mid- high 90%\ns UOP 60-100ml/hr.\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353514, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 01:03 AM\n large amt ectopy, irregular supraventricular rhythm w/ new TWI in I,\n II, aVF and V4 while pt. asleep.\n Potassium repleted\n Was desatting on Bipap while asleep, RT increased Ipap and Epap and she\n responded well.\n Yelling in Farsi, per daughter this is normal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 05:46 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: 36.3\nC (97.3\n HR: 63 (50 - 79) bpm\n BP: 110/35(55) {90/28(45) - 126/74(84)} mmHg\n RR: 22 (17 - 26) insp/min\n SpO2: 86%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 743 mL\n 54 mL\n PO:\n 490 mL\n 30 mL\n TF:\n IVF:\n 253 mL\n 24 mL\n Blood products:\n Total out:\n 1,123 mL\n 173 mL\n Urine:\n 1,123 mL\n 173 mL\n NG:\n Stool:\n Drains:\n Balance:\n -380 mL\n -119 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 86%\n ABG: ///45/\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 206 K/uL\n 9.5 g/dL\n 115 mg/dL\n 1.1 mg/dL\n 45 mEq/L\n 3.4 mEq/L\n 37 mg/dL\n 95 mEq/L\n 143 mEq/L\n 27.3 %\n 7.3 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n WBC\n 4.7\n 7.3\n Hct\n 30.2\n 27.3\n Plt\n 225\n 206\n Cr\n 1.2\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n Other labs: CK / CKMB / Troponin-T:29//<0.01, D-dimer:1023 ng/mL,\n Lactic Acid:0.8 mmol/L, Ca++:9.3 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: Patient\ns admission ABG with pCO2 at patient\ns baseline, but\n normal pH, indicating a superimposing metabolic alkalosis on top of and\n opposing chronic CO2 retension/respiratory acidosis. Metabolic\n alkalosis likely secondary to increased Lasix and contraction\n alkalosis. Her dyspnea is likely a combination of chronic ventillatory\n failure and contraction alkalosis.\n No evidence for CHF (BNP 487), pneumonia (CXR without infiltrates), PE,\n or cardiac ischemia (EKG unchanged).\n - cont. BiPap\n - cont. home doses of advair, tiotropium and albeterol\n - stop prednisone, unlikely to be a COPD exacerbation.\n - hold diuresis as exam and labs (increased BUN/Cr) are consistent with\n being intravascularly dry\n .\n # Altered mental status/somnolence: Orientation at baseline. Increased\n somnolence likely related to metabolic abnormalities, hypercarbia in\n the setting of BiPAP non-compliance, and multiple medications including\n oxycodone. No white count or fever to suggest infection.\n - avoid opiates\n - use BiPAP at night\n - f/u UCx\n - f/u MS exam\n .\n # Neck pain: Likely musculoskeletal vs. DJD changes. have nerve\n impingement in the C2 region based on her pain. Normal strength. CT C\n spine done on as outpatient (ordered by PCP) which showed\n degenerative changes and limited study due to cervical positioning in\n lateral film. Pt cannot have MRI of her C spine due to her ICD.\n - ultram stopped in the past due to sleepiness.\n - avoiding narcotics per above.\n - tylenol around the clock\n - will consider lidoderm patch\n .\n #CAD: h/o CABG. No chest pain or EKG changes.\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: as above.\n .\n # DMII, controlled. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353507, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep and tolerating. Insulin gtt\n titrated off. Large amt of ectopy noted- sinus irregular, ? sm amt\n intermittent Afib, multi-focal PVC\ns, pacer setting on for SB 40\ns and\n noted V Pacing. Cardiac enzymes sent and D Dimer sent to ROMI, R/O PE.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital, PEERLA\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353501, "text": "Events: Titrated down to 5 L NC pre BiPAP- tolerating BiPAP w/ soft\n wrist restrains\n then falling asleep.\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 88-low 90\ns on 5 L NC, 88- low 90\ns on BiPAP w/ adjusting to new\n settings, 15 L\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside, and via phone translation when awake alert oriented\n to self, hospital\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353474, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear - diminished at bilateral bases. RRR. Denies shortness of\n breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face mask of 80%.\n BIPAP placed overnight. O2 sats 97-100% Non-productive cough. Afebrile.\n Action:\n Given MDIs and nebs. Pt cont on Hi-flow FM- sating 92-98%%.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt sleepy but follows commands, Pupils equal and reactive, assists w/\n turns. Pt is Persian speaking- understands & speaks some English. Able\n to communicate her needs. C/o neck pain. ..pt w/ chronic neck pain. No\n s/s of seizure activity.\n Action:\n Given tyelenol q 6h & psych meds.\n Response:\n No change\n Plan:\n Cont to monitor MS closely, hold narcotics, cont w/ current psych\n regimen of psych meds.\n Hyperglycemia\n Assessment:\n Blood sugars 200s-400s. Whole blood glucose 430.\n Action:\n Started on insulin gtt- titrated according to sliding scale.\n Prednisone d/c\n Response:\n Blood sugars improving, anion gap closed\n Plan:\n Cont w/ hourly blood sugars, monitor labs.\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353475, "text": "72 yo female with h/o CHF/COPD/CAD who is admitted in the setting of\n recent worsening of orthopnea and increased diuretic dosing at home.\n She is admitted with respiratory failure and requirement for BIPAP in\n the setting of known obstructive lung disease and narcotic use for\n chronic neck pain. She has a profound elevation of HCO3-suggesting\n significant chronic compromise of ventilation. She in response to\n intervention has had improvement in alertness and responsiveness.\n Initial ABG was 7.40/75/76 which represents significant combination of\n respiratory acidosis and metabolic alkalosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear - diminished to bilateral bases. RRR. Denies shortness of\n breath. PCO2 at baseline (70s-80s). Rec\nd on Hi-flow face mask of 80%.\n BIPAP placed overnight. O2 sats 97-100%. Non-productive cough.\n Afebrile.\n Action:\n Given MDIs and nebs. O2 titrated\ncont on Hi-flow FM- sating 92-98%%.\n Response:\n No change\n Plan:\n Cont w/ neb txs and MDIs, bipap as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt alert, following commands, Pupils equal and reactive, assists w/\n turns. Pt is Persian speaking- understands & speaks some English. Able\n to communicate her needs. C/o neck pain. ..pt w/ chronic neck pain. No\n s/s of seizure activity. Pt mumbling and singing\ns daughter states\n this is her normal MS.\n Action:\n Given tyelenol q 6h & psych meds.\n Response:\n No change\n Plan:\n Cont to monitor MS closely, hold narcotics, cont w/ current psych\n regimen of psych meds.\n Hyperglycemia\n Assessment:\n Blood sugars 200s-400s. Whole blood glucose 430.\n Action:\n Started on insulin gtt- titrated according to sliding scale.\n Prednisone d/c\n Response:\n Blood sugars improving, anion gap closed\n Plan:\n Cont w/ hourly blood sugars, monitor labs.\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353720, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mg Motrin given x1 with out effect ,Given Ultram 25 X 1 PO,\n emotional support and reviewed POC\n Response:\n Able to sleep for a while, wake up after a whle ,shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? Anxiety contributing to pain- Zyprexa , PRN for sleep.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling sleep noted sec apnea. Pt was\n able to use and sleep with BIPAP on.\n Action:\n Given Neb treatment and cont 3L NC. 3L NC at home sats in high 80,s to\n low 90\n Response:\n Sats stayed from 88-92%.\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhalers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation (Farsi speaking only), pt alert,\n oriented to self and place per translation occasionally shouting,\n , and follows commands and able to scoot up in bed with\n supervision.\n Action:\n able to make work sentences, will state\nnot OK\n and\ndown\nvery pain\n no pain.\n Response:\n Sleeping comfortably right now.\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U , Neuro\n consulted and would need translation,- currently optimizing sleep/wake\n cycle, cont pain management, anxiety and psychiatric management. Out\n patient Sleep study when she go to rehab.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA d had this morning, held Lopressor Low HR.\n Response:\n No acute change, no CP\n Plan:\n Monitor vital signs closely, cont meds.\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353724, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mg Motrin given x1 with out effect ,Given Ultram 25 X 1 PO,\n emotional support and reviewed POC\n Response:\n Able to sleep for a while, wake up after a while shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? Anxiety contributing to pain- Zyprexa , PRN for sleep.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling sleep noted sec apnea. Pt was\n able to use and sleep with BIPAP on.\n Action:\n Given Neb treatment and cont 3L NC. 3L NC at home sats in high 80,s to\n low 90\n Response:\n Sats stayed from 88-92%.\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhalers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation (Farsi speaking only), pt alert,\n oriented to self and place per translation occasionally shouting,\n , and follows commands and able to scoot up in bed with\n supervision.\n Action:\n able to make work sentences, will state\nnot OK\n and\ndown\nvery pain\n no pain.\n Response:\n Sleeping comfortably right now.\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U, Neuro\n consulted and would need translation,- currently optimizing sleep/wake\n cycle, cont pain management, anxiety and psychiatric management. Out\n patient Sleep study when she go to rehab.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA d had this morning, held Lopressor Low HR.\n Response:\n No acute change, no CP\n Plan:\n Monitor vital signs closely, cont meds.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n HYPOXIA\n Code status:\n DNI (do not intubate)\n Height:\n 65 Inch\n Admission weight:\n 88.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: COPD, Diabetes - Insulin, Smoker\n CV-PMH: CAD, CHF, Hypertension\n Additional history: Scizophrenia, L3 fracture, Symptomatic VT,\n Hypothyroidism,\n Surgery / Procedure and date: CABG '\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:39\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 350 mL\n 24h total out:\n 580 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:00 AM\n Potassium:\n 4.3 mEq/L\n 04:00 AM\n Chloride:\n 96 mEq/L\n 04:00 AM\n CO2:\n 42 mEq/L\n 04:00 AM\n BUN:\n 33 mg/dL\n 04:00 AM\n Creatinine:\n 1.1 mg/dL\n 04:00 AM\n Glucose:\n 77 mg/dL\n 04:00 AM\n Hematocrit:\n 29.6 %\n 04:00 AM\n Finger Stick Glucose:\n 234\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: MICU685\n Transferred to: \n Date & time of Transfer: 1600\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353725, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mg Motrin given x1 with out effect ,Given Ultram 25 X 1 PO,\n emotional support and reviewed POC\n Response:\n Able to sleep for a while, wake up after a while shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? Anxiety contributing to pain- Zyprexa , PRN for sleep.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling sleep noted sec apnea. Pt was\n able to use and sleep with BIPAP on.\n Action:\n Given Neb treatment and cont 3L NC. 3L NC at home sats in high 80,s to\n low 90\n Response:\n Sats stayed from 88-92%.\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhalers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation (Farsi speaking only), pt alert,\n oriented to self and place per translation occasionally shouting,\n , and follows commands and able to scoot up in bed with\n supervision.\n Action:\n able to make work sentences, will state\nnot OK\n and\ndown\nvery pain\n no pain.\n Response:\n Sleeping comfortably right now.\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U, Neuro\n consulted and would need translation,- currently optimizing sleep/wake\n cycle, cont pain management, anxiety and psychiatric management. Out\n patient Sleep study when she go to rehab.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA d had this morning, held Lopressor Low HR.\n Response:\n No acute change, no CP\n Plan:\n Monitor vital signs closely, cont meds.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n HYPOXIA\n Code status:\n DNI (do not intubate)\n Height:\n 65 Inch\n Admission weight:\n 88.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: COPD, Diabetes - Insulin, Smoker\n CV-PMH: CAD, CHF, Hypertension\n Additional history: Scizophrenia, L3 fracture, Symptomatic VT,\n Hypothyroidism,\n Surgery / Procedure and date: CABG '\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:39\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 350 mL\n 24h total out:\n 580 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:00 AM\n Potassium:\n 4.3 mEq/L\n 04:00 AM\n Chloride:\n 96 mEq/L\n 04:00 AM\n CO2:\n 42 mEq/L\n 04:00 AM\n BUN:\n 33 mg/dL\n 04:00 AM\n Creatinine:\n 1.1 mg/dL\n 04:00 AM\n Glucose:\n 77 mg/dL\n 04:00 AM\n Hematocrit:\n 29.6 %\n 04:00 AM\n Finger Stick Glucose:\n 234\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: MICU685\n Transferred to: \n Date & time of Transfer: 1600\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353726, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mg Motrin given x1 with out effect ,Given Ultram 25 X 1 PO,\n emotional support and reviewed POC\n Response:\n Able to sleep for a while, wake up after a while shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? Anxiety contributing to pain- Zyprexa , PRN for sleep.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling sleep noted sec apnea. Pt was\n able to use and sleep with BIPAP on.\n Action:\n Given Neb treatment and cont 3L NC. 3L NC at home sats in high 80,s to\n low 90\n Response:\n Sats stayed from 88-92%.\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhalers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation (Farsi speaking only), pt alert,\n oriented to self and place per translation occasionally shouting,\n , and follows commands and able to scoot up in bed with\n supervision.\n Action:\n able to make work sentences, will state\nnot OK\n and\ndown\nvery pain\n no pain.\n Response:\n Sleeping comfortably right now.\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U, Neuro\n consulted and would need translation,- currently optimizing sleep/wake\n cycle, cont pain management, anxiety and psychiatric management. Out\n patient Sleep study when she go to rehab.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA d had this morning, held Lopressor Low HR.\n Response:\n No acute change, no CP\n Plan:\n Monitor vital signs closely, cont meds.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n HYPOXIA\n Code status:\n DNI (do not intubate)\n Height:\n 65 Inch\n Admission weight:\n 88.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: COPD, Diabetes - Insulin, Smoker\n CV-PMH: CAD, CHF, Hypertension\n Additional history: Scizophrenia, L3 fracture, Symptomatic VT,\n Hypothyroidism,\n Surgery / Procedure and date: CABG '\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:39\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 350 mL\n 24h total out:\n 580 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:00 AM\n Potassium:\n 4.3 mEq/L\n 04:00 AM\n Chloride:\n 96 mEq/L\n 04:00 AM\n CO2:\n 42 mEq/L\n 04:00 AM\n BUN:\n 33 mg/dL\n 04:00 AM\n Creatinine:\n 1.1 mg/dL\n 04:00 AM\n Glucose:\n 77 mg/dL\n 04:00 AM\n Hematocrit:\n 29.6 %\n 04:00 AM\n Finger Stick Glucose:\n 234\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: MICU685\n Transferred to: \n Date & time of Transfer: 1600\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353581, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times and chanting,\n otherwise pleasant & cooperative (h/o schizophrenia). Pt dozing on and\n off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid, cont to hold\n oxycodone.\n Response:\n MS much improved since stopping home regimen of oxycodone.\n Plan:\n Cont to monitor MS, hold narcotics & start gabapentin HS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 3L via NC w/ sats in low 90s\n Pt is on home O2\n of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time as pt is euvolemic at this time, bipap during any periods of\n sleep.\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353582, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times and chanting,\n otherwise pleasant & cooperative (h/o schizophrenia). Pt dozing on and\n off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid, cont to hold\n oxycodone.\n Response:\n MS much improved since stopping home regimen of oxycodone.\n Plan:\n Cont to monitor MS, hold narcotics & start gabapentin HS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 3L via NC w/ sats in low 90s\n Pt is on home O2\n of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time as pt is euvolemic at this time, bipap during any periods of\n sleep.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VSS, HR mid+-50s\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353583, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times, moaning, and\n chanting. Pt otherwise pleasant & cooperative (h/o schizophrenia). Pt\n dozing on and off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid, cont to hold\n oxycodone.\n Response:\n MS much improved since stopping home regimen of oxycodone.\n Plan:\n Cont to monitor MS, hold narcotics & start gabapentin HS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 3L via NC w/ sats in low 90s\n Pt is on home O2\n of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time as pt is euvolemic at this time, bipap during any periods of\n sleep.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VSS, HR mid--50s-70s. BP 97-120s systolic. Pt w/ rare atrial\n multifactorial ectopy & irregular superventricular rhythm.\n Action:\n EKG done. Cardiac enzymes flat.\n Response:\n Mild EKG changes.\n Plan:\n Cont w/ ASA, Statin, and metropolol, ? need for outpatient stress test\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353585, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times, moaning, and\n chanting. Pt otherwise pleasant & cooperative (h/o schizophrenia). Pt\n dozing on and off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid, cont to hold\n oxycodone.\n Response:\n MS much improved since stopping home regimen of oxycodone.\n Plan:\n Cont to monitor MS, hold narcotics & start gabapentin HS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 3L via NC w/ sats in low 90s\n Pt is on home O2\n of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time as pt is euvolemic at this time, bipap during any periods of\n sleep.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VSS, HR mid--50s-70s. BP 97-120s systolic. Pt w/ rare atrial\n multifactorial ectopy & irregular superventricular rhythm.\n Action:\n EKG done. Cardiac enzymes flat.\n Response:\n Mild EKG changes.\n Plan:\n Cont w/ ASA, Statin, and metropolol, ? need for outpatient stress test\n" }, { "category": "Nursing", "chartdate": "2131-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353587, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ chronic neck pain and headache.\n Action:\n Given 650mg Tylenol po @ 0600. heating pads applied to neck.\n Response:\n Pt resting comfortably\n Plan:\n Neuro consult for pt\ns chronic neck pain & strategies to manage pain,\n gabapentin ordered HS for possible nerve impingement on neck.\n Hyperglycemia\n Assessment:\n Pt rec\nd off of Insulin gtt w/ Blood sugars in the 70s this am.\n Action:\n Insulin s/s restarted.\n Response:\n Blood sugars this afternoon 217.\n Plan:\n Cont to monitor blood sugars closely, diabetic diet education\n Altered mental status (not Delirium)\n Assessment:\n MS @ baseline per pt\ns daughter-shouting out at times, moaning, and\n chanting. Pt otherwise pleasant & cooperative (h/o schizophrenia). Pt\n dozing on and off, following commands. No s/s of seizure activity.\n Action:\n Cont w/ home regimen of psych meds and valproic acid, cont to hold\n oxycodone.\n Response:\n MS much improved since stopping home regimen of oxycodone.\n Plan:\n Cont to monitor MS, hold narcotics & start gabapentin HS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear w/ some rhonchi to bases. Rec\nd on 5L NC w/ O2 sats of 95%.\n RRR, no distress. Cont to be mildly congested- this is pt\ns baseline\n per daughter.\n Action:\n spiriva and advair w/ albuterol nebs.\n Response:\n Able to wean O2 down to 4L via NC w/ sats in the low 90s\n Pt is on\n home O2 of 3L.\n Plan:\n Maintain O2 in the low 90s, pulmonary toileting, hold lasix at this\n time as pt is euvolemic at this time, bipap during any periods of\n sleep.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VSS, HR mid--50s-70s. BP 97-120s systolic. Pt w/ rare atrial\n multifactorial ectopy & irregular superventricular rhythm.\n Action:\n EKG done. Cardiac enzymes flat.\n Response:\n Mild EKG changes.\n Plan:\n Cont w/ ASA, Statin, and metropolol, ? need for stress test/echo.\n" }, { "category": "Physician ", "chartdate": "2131-12-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 353680, "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 72 yo women with severe COPD, CHF, admitted with acute on chronic\n respiratory failure.\n 24 Hour Events:\n EKG - At 08:30 AM\n Has been complaining of neck and head pain. TX with advil and\n neurontin.\n Has had intermittent desaturations. Taking bipap off periodically.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n lipitor\n resperidone\n sertraline\n valproate\n lopressor\n adiprazole\n Calcium\n levoxyl\n protonix\n SSI\n glyburide\n digoxin\n asa\n medroxyprogesterone\n colace\n neurontin\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: No(t) Dyspnea\n Psychiatric / Sleep: Daytime somnolence\n Flowsheet Data as of 10:50 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: 72 (49 - 78) bpm\n BP: 107/53(66) {90/25(46) - 127/97(94)} mmHg\n RR: 22 (15 - 29) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,094 mL\n 250 mL\n PO:\n 1,070 mL\n 250 mL\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 1,363 mL\n 375 mL\n Urine:\n 1,363 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 85%\n ABG: ///42/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\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: Diminished: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, sleepy\n Labs / Radiology\n 10.2 g/dL\n 191 K/uL\n 77 mg/dL\n 1.1 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 96 mEq/L\n 142 mEq/L\n 29.6 %\n 8.1 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n 04:00 AM\n WBC\n 4.7\n 7.3\n 8.1\n Hct\n 30.2\n 27.3\n 29.5\n 29.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n 77\n Other labs: PT / PTT / INR:12.3/23.1/1.0, CK / CKMB /\n Troponin-T:29//<0.01, D-dimer:1023 ng/mL, Lactic Acid:0.8 mmol/L,\n Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE): Contineu ASA,\n Toprol. No need for dig. as EF is preserved and not in AF.\n .H/O PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACUTE PAIN: Still complaining of severe headaches. Adding\n neurontin. Continue advil, lido patch. Likely OSA is playing a role\n in chronic headaches.\n HYPERGLYCEMIA\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Continue BIPAP for\n obesity hypoventilation when sleeping.\n ALTERED MENTAL STATUS (NOT DELIRIUM): MS \nICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353704, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353706, "text": "Events: Agitated on arrival- HA throughout most of day. Meeting w/\n daughter, RN and MD for plan for pain control. Called in and plan for\n monitoring on BiPAP overnight in MICU ? C/O in AM. Given SL ,\n scheduled medications, additional Motrin and able to tolerate BiPAP\n overnight. ? new BiPAP needs- cont to be low to mid 80\ns to low 90\ns on\n new BiPAP levels. Desat to 78% w/ sleep apnea if off BiPAP. Low MAP 88-\n to low 50\ns while asleep.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self but per\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353708, "text": ".H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self but per\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353709, "text": ".H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self but per\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353710, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mgotrin given x1 with out effect ,started on Ultram 25 PO,\n emotional support and reviewed POC\n Response:\n Able tosleep for a while, wake up after a whle ,shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- woeked last nioght\n able to sleep with BIPAP .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling asleep noted sec apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self but per\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 353713, "text": "What appears to be likely is a combination of chronic ventilatory\n failure and chronic heart failure both needing ongoing stabilization of\n ventilatory failure and congestive heart failure/atrial arrhythmia.\n" }, { "category": "Respiratory ", "chartdate": "2131-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 353399, "text": "Pt received from ED on NIV mask and vent. Pt on for a few hours and\n abg drawn. Results were normal for pt\ns condition and pt then placed on\n High Flow O2. Nebs given as ordered.\n" }, { "category": "Physician ", "chartdate": "2131-12-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353400, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:59 PM\n Allergies:\n No Known Drug Allergies\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 05:49 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: 68 (60 - 77) bpm\n BP: 105/86(91) {100/37(52) - 128/86(91)} mmHg\n RR: 25 (15 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 430 mL\n 250 mL\n Urine:\n 430 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -430 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 579 (332 - 579) mL\n PS : 10 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 17 cmH2O\n SpO2: 96%\n ABG: 7.40/75/76./47/16\n Ve: 6.8 L/min\n PaO2 / FiO2: 217\n Physical Examination\n General: NAD, sleepy, opens eyes to verbal stimuli, Farsi-speaking\n only\n HEENT: NCAT, anicteric, chronic left sided droop per ED team who have\n taken care of her in the past, no injections, OP clear, MMM\n Neck: no LAD, supple, no jvd\n Heart: RRR no m/r/g\n Lungs: coarse diffuse inspiratory breath sounds on BiPAP, no crackles\n or wheezes.\n Abd: mildly distended, +BS, NT, soft, no mass or organomegaly.\n Ext: trace edema\n Neuro: moving all extremities spontaneously, finger grip and plantar\n flexion bilaterally, normal muscle tone.\n Psych: sleepy but following commands, oriented to self and hospital,\n not date (baseline per daughter)\n Skin: no rashes\n / Radiology\n 225 K/uL\n 10.3 g/dL\n 201 mg/dL\n 1.2 mg/dL\n 47 mEq/L\n 3.7 mEq/L\n 33 mg/dL\n 94 mEq/L\n 145 mEq/L\n 30.2 %\n 4.7 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n WBC\n 4.7\n Hct\n 30.2\n Plt\n 225\n Cr\n 1.2\n TCO2\n 48\n Glucose\n 232\n 201\n Other : Lactic Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: Most likely due to COPD exacerbation. Requires home oxygen\n and BiPAP but known not compliant with BiPAP. Pt was at her baseline\n CO2 on ABG. She was noted to often remove her BiPAP intermittently at\n night. Overmedication with oxycodone may play a role as well. Patient\n has known CHF with EF of 40%. CXR shows mild edema but not significant\n to explain her hypoxia. BNP 487 near baseline. PE will be on the\n differential but pt was unable to tolerate CTA. CXR with no evidence\n of infection. No leukocytosis. Received lovonex 125 mg IV once in\n ED. Unlikely to be ischemia without chest pain and without ischemic\n EKG changes.\n - BiPap\n - advair, tiotropium and albeterol\n - prednisone 60 mg daily, fast taper if patient improves\n - will hold on diuresis as exam and (increased BUN/Cr) are\n consistent with being intravascularly dry\n .\n # Altered mental status: Orientation at baseline. Likely hypercarbia\n in the setting of BiPAP non-compliance and multiple medications\n including oxycodone. No white count or fever to suggest infection.\n - will try a small dose of narcan\n - UA normal\n - UCx is pending\n .\n # Neck pain: Likely musculoskeletal vs. DJD changes. have nerve\n impingement in the C2 region based on her pain. Normal strenth.\n CT C spine done on as outpatient (ordered by PCP) which\n showed degenerative changes and limited study due to cervical\n positioning in lateral film. Pt cannot have MRI of her C spine\n due to her ICD.\n - ultram stopped in the past due to sleepiness.\n - tylenol around the clock\n - could consider lidoderm patch\n .\n #CAD: h/o CABG. No chest pain or EKG changes.\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: as above.\n .\n # DMII, controlled. ? diabetic retinopathy.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Treated with her metoprolol.\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed. Currently at baseline HCT, low 30s.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353403, "text": "72 yo woman who presented to the ED with worsening SOB, LE edema, and\n neck pain. 3 days PTA she started called daughter more often and\n daughter noticed her sleeping upright. Visiting nurse \n on exam in increasing LE edema, so PCP increased lasix dose. daughter\n also noticed occasional confusion, especially when taking her\n oxycodone. In ED Temp 98.8, HR89, BP 102/65, Sat 86% on RA, RR25. ABG\n 7.37/78/62. Recent CO2s 70-80s. Has bipap at night prescribed, but\n has not been wearing it lately. Got Lasix and solumedrol in ED. Got\n lovenox for possible PE.\n Pt was on BiPap upon arrival to the MICU, w/ 02 sat\ns in the mid 90%\n pt more awake after arrival in the MICU, pulling at BiPap mask,\n desatting immediately when mask off, ABG done, 7.40/75/76, Bipap\n removed and pt now on HiFlo 02 mask 80%, w/ 02 sats in the mid to high\n 90%\ns. pt more compliant w/ mask. Agitated at times, speaks little\n English but per daughter understands .\n" }, { "category": "Nursing", "chartdate": "2131-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353494, "text": "Events: Titrated down to 5 L NC pre BiPAP-\n Hyperglycemia\n Assessment:\n FS cont to remain around 300 @ beginning of shift\n Action:\n Insulin gtt titrated up- new order for increasing FS glucose\n Response:\n Plan:\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" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353605, "text": "Events: Agitated on arrival- HA throughout most of day. Meeting w/\n daughter, RN and MD for plan for pain control. Called in and plan for\n monitoring on BiPAP overnight in MICU ? C/O in AM. Given SL Zyprexa,\n scheduled medications, additional Motrin and able to tolerate BiPAP\n overnight. ? new BiPAP needs- cont to be low to mid 80\ns to low 90\ns on\n new BiPAP levels. Desat to 78% w/ sleep apnea if off BiPAP. Low MAP 88-\n to low 50\ns while asleep.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- Zyprexa @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n anea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353606, "text": "Events: Agitated on arrival- HA throughout most of day. Meeting w/\n daughter, RN and MD for plan for pain control. Called in and plan for\n monitoring on BiPAP overnight in MICU ? C/O in AM. Given SL ,\n scheduled medications, additional Motrin and able to tolerate BiPAP\n overnight. ? new BiPAP needs- cont to be low to mid 80\ns to low 90\ns on\n new BiPAP levels. Desat to 78% w/ sleep apnea if off BiPAP. Low MAP 88-\n to low 50\ns while asleep.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to slef but epr\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353607, "text": "Events: Agitated on arrival- HA throughout most of day. Meeting w/\n daughter, RN and MD for plan for pain control. Called in and plan for\n monitoring on BiPAP overnight in MICU ? C/O in AM. Given SL ,\n scheduled medications, additional Motrin and able to tolerate BiPAP\n overnight. ? new BiPAP needs- cont to be low to mid 80\ns to low 90\ns on\n new BiPAP levels. Desat to 78% w/ sleep apnea if off BiPAP. Low MAP 88-\n to low 50\ns while asleep.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sever HA- per translation via daughter unable to describe other than\nsharp pain\n pt also very agitated @ that time, w/ plan and emotional\n support of daughter decrease in pt shouting\n Action:\n 650mg PO Motrin, Q6hr Acetaminophen, urojet for pain w/ foley catheter,\n repositioned, emotional support and review of medications and POC,\n given 300mg Gabapentin\n Response:\n Able to state HA pain,\n better\n and pt appearing sig more comfortable, able to sleep on BiPAP\n overnight\n Plan:\n Con Q6hr Acetminophen, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- @ night w/ great\n effect\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 86-low 90\ns on NC while awake, when falling asleep noted sec\n apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to slef but epr\n translation\njust want to go home\n, frequently shouting, PEELA, MAE and\n follows commands\n Action:\n Post , translation, alert, orientation @ baseline ,\n nodding, able to make work sentences, will state\nnot OK\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA due in AM, ? repete EKG- new variable changed w/ plan outpt stress\n test, ROMI previous day\n Response:\n No acute change, no CP\n Plan:\n Support HS stability, maintain blood sugar w/I goal range, cont\n medication regimin\n" }, { "category": "Physician ", "chartdate": "2131-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 353716, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:30 AM\n -Continued neck and head pain throughout day, agitation\n - Started Ibuprofen TID, neurotin, zyprexa\n -Increased ISS\n -Given PO lasix 20mg x1 for desat\n -pt repeatally desat to mid 80s throughout day and night (moaning /\n singing throughout).\n - On bipap overnight titrating dose, pt repeatally breaks seal of bipap\n with hand and desats\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 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 06:18 AM\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: 36.7\nC (98.1\n HR: 60 (49 - 74) bpm\n BP: 122/45(65) {92/25(46) - 127/77(84)} mmHg\n RR: 24 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Telemetry: PVCs, HR 44\n Total In:\n 1,094 mL\n PO:\n 1,070 mL\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 1,363 mL\n 210 mL\n Urine:\n 1,363 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 100%\n ABG: ///42/\n Physical Examination\n GEN: Pt asleep, responsive to touch.\n HEENT: NCAT MMM, tender with movement of neck\n Lungs: scattered crackles at bases otherwise good air movement\n Heart: RRR, II/VI systolic murmur\n Abd: Soft, NT, ND, BS+\n EXT: No peripheral edema\n Peripheral Vascular: 2+ radial and DP pulses symmetric\n Labs / Radiology\n 191 K/uL\n 10.2 g/dL\n 77 mg/dL\n 1.1 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 96 mEq/L\n 142 mEq/L\n 29.6 %\n 8.1 K/uL\n [image002.jpg]\n 12:21 AM\n 03:22 AM\n 02:44 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 01:00 AM\n 07:55 AM\n 04:00 AM\n WBC\n 4.7\n 7.3\n 8.1\n Hct\n 30.2\n 27.3\n 29.5\n 29.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n <0.01\n TCO2\n 48\n Glucose\n 232\n 201\n 431\n 370\n 296\n 306\n 115\n 77\n Other labs: PT / PTT / INR:12.3/23.1/1.0, CK / CKMB /\n Troponin-T:29//<0.01, D-dimer:1023 ng/mL, Lactic Acid:0.8\n mmol/L,Ca++:9.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Pt is a 72 yo female with PMHx of CAD, COPD, CHF EF 40% here with\n altered mental status and dyspnea.\n .\n # Dyspnea: Has improved over the course of admission with use of bipap\n intermittently. Pt. does not appear hypervolemic and is not having\n productive cough. Will continue to work on appropriate bipap settings\n and avoid sedating meds as this is likely what exacerbated her\n respiratory status over the weekend. Currently doing well on 3L O2 NC\n but should be on bipap when sleeping.\n - new Bipap settings\n - avoid opioids, sedating meds\n - Continue nebs\n - Would benefit from an outpatient sleep study\n .\n # Altered mental status/somnolence: Appears improved and at baseline,\n with intermittent episodes of agitation and c/o pain.\n -continue psych meds\n -avoid sedating medications\n -zyprexa prn for agitation\n .\n # Neck pain/Headache: This is a chronic issue for her. NSAIDs are a\n problem given her poor renal status. Per neurology, started neurontin\n to see if this alleviates some of her pain. Toradol may also be better\n than NSAIDs in general (both for pain and to avoid further renal\n insult) .\n - Neurontin up to 100 po tid\n - Standing Tylenol\n - Tramadol IV prn, try avoiding NSAIDs\n .\n #CAD: h/o CABG. Has been having\nHeart pain\n at home and taking\n nitro. Currently asymptomatic. Have continued her home regimen of ASA,\n statin and beta blocker.\n - Consider outpt stress post discharge\n - cont ASA, statin, Toprol XL\n .\n # Chronic diastolic CHF: Euvolemic, not actively diuresing. Unsure why\n patient is on digoxin for diastolic dysfunction, will stop for now and\n monitor hemodynamics.\n .\n # DMII: Increased insulin for elevated glucose, now under better\n control.\n - continue home glyburide\n - FS QID with SSI while in house.\n .\n #HTN: Well controlled on metoprolol\n .\n # Hypothyroidism: Continued levothyroxine\n .\n # Anemia: No evidence of bleed, hct at baseline. Will avoid NSAIDs.\n .\n # Schizophrenia: continued aripiprazole, depakote, and risperdal\n .\n # FEN: Cardiac heart healthy; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI, bowel regimen\n .\n CODE: Per daughter DNR/, but has ICD in place and on.\n .\n CONTACT: HCP Daughter \n .\n Dispo: Will call-out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 PM\n 18 Gauge - 04:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 353717, "text": "72 yo female with h/o COPD, neck pain on narcotics for control and CHF\n now admit with increasing lethargy at home and worsening dyspnea. She\n had mixed respiratory acidosis and metabolic alkalosis at admission in\n the setting of increasing lasix dosing at home. Overnight patient with\n significant arrhythmia and requirement for up-titration of BIPAP\n overnight with persistent and significant hypoxemia noted across the\n night. This likely represents a challenging combination of chronic\n obstructive lung disease, congestive heart failure and restriction in\n the setting of obesity which with sleep onset may all conspire to\n compromise venilatory function particularly during sleep requiring\n up-titration of BIPAP therapy.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Cont complain severe neck pain and Sever HA- per translation via\n daughter .screams always while she awake.\n Action:\n 400 mgotrin given x1 with out effect ,started on Ultram 25 PO,\n emotional support and reviewed POC\n Response:\n Able tosleep for a while, wake up after a whle ,shouting for pain\n Plan:\n Con Q6hr Acetminophen PRN, emotional support, PRN Motrin- monitor renal\n function, ? anxiety contributing to pain- Zyprexa woeked last nioght\n able to sleep with BIPAP .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 3L NC, when falling asleep noted sec apnea\n Action:\n Placed in BiPAP\n Response:\n Sat variable on BiPAP mid 80\ns to low 90\ns w/ setting as - but\n different from home, 15L O2 and unable to titrate down\n Plan:\n On 3L NC @ baseline, cough & deep breath, ? restarting home PO Lasix,\n nebulizers and inhailers,\n Altered mental status (not Delirium)\n Assessment:\n Daughter @ bedside for translation, pt alert, oriented to self and\n place per translation occasionally shouting, PERLA, MAE and follows\n commands and able to scood up in bed with supervision.\n Action:\n able to make work sentences, will state\nnot OK\n and\ndown\n Response:\n Sleeping overnight\n Plan:\n Cont frequent orientation, ? Farsi interpreter for further W/U in AM,\n Neuro consulted and would need translation,- currently optimizing\n sleep/wake cycle, cont pain management, anxiety and psychiatric\n managment\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR dropping while asleep to SB/SA- sinus irregular 40-50\ns, occ V Paced\n w/ additional pacer spikes noted\n Action:\n ASA d had this morning,held Lopressor Low HR.\n Response:\n No acute change, no CP\n Plan:\n Monitor vital signs closely,cont meds.\n" }, { "category": "Radiology", "chartdate": "2131-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1048486, "text": " 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with 3days increase SOB and edema\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old female with three days of increasing shortness of breath\n and edema, to assess for a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with radiograph of .\n\n FINDINGS:\n The heart is enlarged, unchanged since the prior examination. There is a\n pacemaker with the tip projected over the right atrium. There is evidence to\n suggest mild pulmonary edema. There is no focal pulmonary consolidation.\n\n CONCLUSION:\n No significant change since the prior examination. Appearances are suggestive\n of mild CHF. Followup radiography is recommended post-diuresis.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1048886, "text": " 7:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: resolution of chf?\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with MMP who presented initially with worsening shortness of\n breath and concern for CHF. would like to eval for improvement.\n REASON FOR THIS EXAMINATION:\n resolution of chf?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY\n\n HISTORY: Short of breath, possible CHF.\n\n One portable view. Comparison with . The lungs now appear clear\n except for minimal bilateral streaky density consistent with subsegmental\n atelectasis. The heart appears enlarged as before. The patient is status\n post median sternotomy. Mediastinal structures are unchanged. An ICD remains\n in place.\n\n IMPRESSION: Subsegmental atelectasis.\n\n\n" }, { "category": "ECG", "chartdate": "2131-12-30 00:00:00.000", "description": "Report", "row_id": 204286, "text": "Rhythm is probably sinus bradycardia with ventricular premature beats and\natrial premature beats. Diffuse non-specific ST-T wave abnormalities.\nCompared to the previous tracing of heart rate has decreased.\nPrecordial QRS voltage has also decreased, raising the question of\nincreased thoracic impedance. Clinical correlation and repeat tracing are\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2131-12-28 00:00:00.000", "description": "Report", "row_id": 204287, "text": "Rhythm is most likely sinus rhythm with frequent atrial premature beats.\nDiffuse ST-T wave changes which are non-specific. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2148-06-10 00:00:00.000", "description": "Report", "row_id": 101468, "text": "PATIENT/TEST INFORMATION:\nIndication: ? AS\nBP (mm Hg): 117/29\nStatus: Inpatient\nDate/Time: at 15:20\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 elongated.\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\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\nsignificant aortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant pulmonic regurgitation is seen.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is elongated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened. There is no significant aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. Significant pulmonic regurgitation is seen. There is a small\npericardial effusion.\n\nCompared with the prior report (tape unavailable) of , there is no\nsignificant change.\n\n\n" }, { "category": "ECG", "chartdate": "2148-05-31 00:00:00.000", "description": "Report", "row_id": 300873, "text": "Sinus rhythm. Diffuse non-specific ST-T wave abnormalities. Slight Q-T interval\nprolongation. Compared to the previous tracing of no diagnostic change.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-12 00:00:00.000", "description": "Report", "row_id": 1473014, "text": "MICU NPN 7A-7P\n\nNeuro: Pt. AAO x 1, pupils equal and reactive, not as responsive verbally as last week but does nod, smile, and say occasional words. MAE. Does not follow commands.\n\nResp: Lungs bilaterally clear upper, decreased lower lobes. O2 sats remain 98-100% on 3L NC.\n\nCV: Pt. has maintained an SBP > 110 for most of the night, with occasional brief dips to 100's while sleeping. Levofed continues to be held secondary to both adequate SBPs and U/O > 30 cc/hr. HR NSR 70-90's. Pt. has + generalized edema.\n\nGI: + BS x 4, still no BM. Abd. soft, distended, slt. tender to touch. Rectal bag intact. Pt. may benefit from beginning bowel regimen today.\nTPN currently running.\n\nGU: Foley patent, draining ~ 40-60 cc/hr of urine.\n\nSkin: Pt. continues to drain lg. amt. serous fluid from bilateral arms, soaking through a pink pad each ~ every 3-4 hours, R>L. Small stage II pressure ulcer on coccyx OTA. Pt. remains on First Step Mattress.\n\nSocial: Pt.'s children in to see pt. at start of shift. Very supportive.\n\nPlan: Possible transfer to floor today if pt. continues to maintain an adequate BP and U/O off of Levofed.\n\nSee CareVue for further details.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-12 00:00:00.000", "description": "Report", "row_id": 1473016, "text": "MICU NPN 7P-11P\n\nNeuro: pt. less responsive than reported prior. Now opening eyes spontaneously, but only moans in response to questions, not saying words. Does not follow commands. Team aware.\n\nGI: + BS x 4, abd. slt. firm, distended. Team aware. NGT placed after multiple attempts - no bile aspirated, but + auscultation of air. CXR done to confirm placement - awaiting results. Plan is to start TF when placement is confirmed. No BM x \n\nGU: Foley patent, draining lg. amt. urine per hr. since admin of Lasix at 1800.\n\nHeme: 2nd unit PRBCs up at ; next Hct with AM labs.\n\nSocial: Family visiting at beginning of the shift; very supportive.\n\nSee CareVue for further details.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-13 00:00:00.000", "description": "Report", "row_id": 1473017, "text": "NURSING NOTE: 11P-7A\n PT AWAKE MOST OF NOC. EYES OPEN. APPEARS UNCOMFORTABLE SINCE NGT PLACEMENT. NOT FOLLOWING COMMANDS. NON-VERBAL BUT MOANING. TEAM AWARE. MEDICATED WITH 1 MG IV MORPHINE WITH SEDATIVE EFFECT.\n\nRESP- LUNG SOUNDS CLEAR BUT DIMINSHED. SATS 93-98% ON 3L N/C. RR 12-22\n\nCV- HR ST 100'S NO ECTOPY NOTED. SBP 130-150 OVERNOC. POST TRANSFUSION HCT PENDING WITH AM LABS.\n\nGI- ABD FIRM, POSITIVE BS, NO STOOL. NO PO MEDS GIVEN. NGT PLACED BY INTERN. CXR REPORTED NEED TO PULL TUBE BACK BY 10 CM. NURSING ADJUSTED NGT, TEAM AWARE, FOLLOW-UP CXR ORDERED FOR THIS AM. PT CONTINUES ON TPN FOR NUTRITION.\n\nGU- FOLEY PATENT FOR LARGE AMONUTS OF CLEAR YELLOW URINE.\n\nSKIN- ARMS CONTINUE TO WEEP. DRAINAGE BAG MAINTAINED ON LEFT ARM, NUMEROUS PAD CHANGES BILATERALLY. COCCYX WITH DUODERM,AREA NOT VISUALIZED. FECAL INCONT BAG REMAINS IN PLACE.\n\nACCESS- RIGHT IJ TLCL SITE WNL, PORTS PATENT.\n\n PT REMAINS IN MICU, AWAITING BED ON FLOOR. MAINTAINING GOOD BP AND U/O OFF LEVOPHED NOW A FEW DAYS. DNR/DNI. AWAITING POSITIVE NGT PLACEMENT BY CXR TO START TF.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-12 00:00:00.000", "description": "Report", "row_id": 1473015, "text": "Nursing Note 7am - 7pm\nN- She's is more awake today, responding well to verbal stimuli, following simple commands, recognizing family members. At 5pm pt became restless, agitated, c/o generalized discomfort, hr in the 120s, medicated with mso4 1mg iv with good effect. Pt still with generalized edema, whoozing from sm skin tears on upper ext. Remains aferile today.\n\nCV- Hr 80s - 90s, sr with occ pvcs, no c/o cp. AM hct 24, repeat down to 23, plt 16, PT transfused with 1u prbc over 4hrs and given 1u plt. Post transfusion, lasix 40mg iv x1 given, when responding to lasix she needs 2nd unit prbc. Bp stable this shift requiring no pressors. Pt is now DNR.\n\nResp- Tol O2 3l np, sats in the high 90s, no cough, bs diminished at bases.\n\nGI/GU- +bs, abd soft but distended, no stool today. uop improved to 60 - 70cc/o cl yellow urine.\n\nSkin- Sm skin tear to buttocks, duoderm in place, multiple sm tears to upper ext, draining moderate amt yellow fluid.\n\nSocial- Multiple family members into visit today, Attending met with daughters to update on pt status. Family members wish to speak with a social worker in am about post hospitalization.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-10 00:00:00.000", "description": "Report", "row_id": 1473011, "text": "NPN P-MICU 7AM-7PM\nS/O: C/V: Remains on Levo Gtt titrating to maintain MAP's >60, able to wean rate from 0.040 mcq/kq/min to 0.025mcq/kq/min. with BP's 106-126/34-46. HR75-95 SR with no ectopy noted. CVP-.\n\nRespir: Remains on 4L NP, RR- with O 2sats 93-99%. L/S clear to diminshed @ bases. No acute SOB noted.\n\nGU: U/O 40-50cc/hr, BUN/CRE 75/1.4(71/1.5). Rec'd 500cc LR IVB times one with little effect.\n\nGI: Remains on TPN, only taking small amts sips of water. No stool noted. Remains on PO Flagyl.\n\nNeuro: Is alert but confused as to time and place. C/O'ing back pain, and overall uncomfortable, rec'ing MSO4 .5mg-1mg q4hr with good effect.\n\nSkin: Continues with body Anasarca in upper extremites and continues to weep fluid, from open areas but drainage has decreased.\n\nID: WBC 12.3(10.4) Temps-96.4 ax max. Continues on IV antibx's.\n\nSocial: Son in visiting and has set up a family meeting to discuss status for tomorrow afternoon @ approx 1-2PM.\n\nA/P: Continue to titrate Levo Gtt, medicate with MSO4 for comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-11 00:00:00.000", "description": "Report", "row_id": 1473012, "text": "NURSING PROGRESS NOTE:\nC/V: PT REMAINS ON LEVOPHED TO MAINTAIN MAP'S GREATER THAN 60. NO ATTEMPTS TO WEAN LEVO OVERNIGHT. HR NSR NO ECTOPY. RESP RATE STABLE.\nCVP 5-8.\nNEURO: PT AWAKE BUT BECOMING MORE LETHARGIC AND NOT SPEAKING AT ALL. SLEPT WELL DURING THE NIGHT. MOVES ARMS BUT NOT LOWER EXTREMETIES. C/O OVERALL DISCOMFORT, MED WITH 1MG MSO4 IV WITH SOME RELIEF. MOANING AT TIMES.\nGI: PT TAKING SMALL SIPS OF CLEAR LIQ, HAD MUCH DIFF SWALLOWING FLAGYL. HELD AM DOSE. NO STOOL AND NO BOWEL SOUNDS HEARD.\nGU: PT RECEIVED FLUID BOLUS OF LR 500CC X2 WITH SMALL RESPONSE IN U/O. PT FOLEY PATENT DRAINING SMALL AMT'S OF CLOUDY YELLOW URINE.\nRESP: REMAINS ON 4L NC WITH GOOD O2SAT'S. LUNG SOUNDS VERY DIMINISHED AT THE BASES. HAD SOME SOB AFTER TRYING TO SWALLOW MEDICATION.\nFAMILY VISITED AND WILL RETURN TODAY FOR FAMILY MEETING.\nPT'S UPPER EXTREMETIES CONT TO WEEP LRG AMT'S OF SEROUS FLUID.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-11 00:00:00.000", "description": "Report", "row_id": 1473013, "text": "MICU NPN 1P-7P\nNEURO: ACCORDING TO MD, MS WORSENED SINCE YESTERDAY. ? METABOLIC BUT CHEMISTRIES WERE OK. CT OF HEAD DONE WHICH WAS NEGATIVE. PATIENT AROUSES TO VOICE, DOES NOT FOLLOW COMMANDS, AND IS LOCALIZING PAIN. HAS NOT RECEIVED ANY ANALGESICS SINCE MIDNOC.\n\nCARDIAC: HR 89-100 SR WIH NO ECTOPY. RECEIVED PATIENT ON 0.020MCG OF LEVOPHED WITH MAPS >60. BP 117-136/25-43. LEVO SHUT OFF @6PM. 4+ EDEMA IN BUE'S, 2+ IN BLE'S. LEGS BETTER AS STATED BY MD AND FAMILY. CONTINUES TO HEAVILY WEEP FROM ARMS. WILL TOLERATE LOW DIASTOLIC OF 20'S AND NOT FOLLOW THE MAPS AS LONG AS SHE IS VOIDING. HCT STABLE AT 29 AND K+ AT 5.5.\n\nRESP: MAINTAINING SATS >98% ON 5L N/C. LS CLEAR WITH DIMINISHED BASES. NO COUGH/CONG/SOB NOTED.\n\nGI: ABD SOFT DISTENDED WITH HYPOACTIVE BS. NO STOOL. NPO, RECEIVING TPN. ? COLITIS RESOLVING/RESOLVED WHEN CAN WE START TUBE FEEDS.\n\nGU: U/O 60/HR YELLOW AND CLEAR.\n\nID: WBC WNL. TMAX 96.5. VANCO HELD AS LEVEL WAS 18. CONTINUES ON FLAGYL AND LEVOQUIN BUT UNABLE TO GIVE FLAGYL AS IT IS PO. ON CONTACT PRECAUTIONS FOR MRSA.\n\nSKIN: REDDENED AREA ON COCCYX, DUODERM INTACT.\n\nACCESS: RIJ CL.\n\nDISPO/PLAN: FAMILY MEETING HELD. PATIENT REMAINS DNR/DNI, BUT WE WILL CONTINUE WITH CURRENT POC. IF CAN TOLERATE LEVO OFF OVERNOC CAN BE CALLED TO FLOOR TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-06 00:00:00.000", "description": "Report", "row_id": 1473003, "text": "MICU NPN 1500-1900\nHistory: see Admission history flowsheet for details.\n\nReview of systems:\n\nNeuro: Pt. is AAO x 3, pleasant. MAE.\n\nResp: R lung: upper CTA, lower faint crackles. L lung: diminished T/O. O2 sat 98-100% on 3L NC.\n\nCV: HR is NSR 70-80's. SBP initially 100-110's with MAPs in the 50's. Multiple boluses given over the course of the day (~ 2L in total) to increase BP and U/O with minimal success. Levofed gtt started; currently @ 0.081 mcg/kg/min (20 mL/hr) with resultant MAPs 58-60. Goal is for MAP>80. CVP 3-4. + 2 generalized edema.\n\nGI: + BS x 4, abd. soft, slt. distended, diffusely tender (no change). Pt. incontinent of golden mucusy stool x 1; guiac neg. FIB applied for better stool management (rectal foley not attempted because of pt.'s low platelet count). No POs attempted. We are attempting to save a clean line on her TLC for ? TPN tomorrow.\n\nGU: Foley patent, draining small amts. cloudy amber urine (~15 cc/hr). U/O increased to 25 cc/hr immediately after 500 cc NSS bolus, but then dropped down again. Continue to monitor.\n\nHeme: Pt. transfused with 5U platelets for plt=25 today. Count pending.\n\nID: Pt. now on IV levaquin, IV flagyl, IV vanco and PO vanco MD (used for 2 different purposes, IV does not affect GI tract and PO does not absorb through GI membrane).\n\nAccess: RUA PICC line D/C'd and tip sent for cx secondary to positive BC from . RSC TLC placed today prior to admission to ICU. Plan is to attempt an A-line when pt.'s platelet count bumps up.\n\nSkin: Upper arms are dark red, painful to touch and movement, but not hot or hard. Dermatology consulted; MD believes that this is due to bleeding in her subcutaneous tissue from multiple traumatic peripheral sticks and low platelet count. Multiple skin tears on BUE oozing serous fluid. BLE with ? venous stasis disoloration. Sacrum with small stage II pressure ulcer. NSS W-D ordered but not applied at this time. Pt. could benefit from a first step mattress. + gout flare-up in L great toe.\n\nPain: Pt. C/O pain from toe, arms and back. Given 0.5 mg MSO4 IV with moderate relief.\n\nSee CareVue for further details.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-07 00:00:00.000", "description": "Report", "row_id": 1473004, "text": "Nursing Progress Note\n\nNeuro: Alert Oriented X3. Follows commands pupils equal and reactive. Moves all extremities equally and purposefully. No deficits noted.\n\nResp: Lungs clear upper bases. Lower diminished. On 4L/NC. O2 Sat 98-100% No resp distress noted. No c/o of SOB.\n\nCV: SR no ectopy. On Levophed gtt at max dose 0.17mcg/kg/min. Goal is MAP > 80 . Map low 60's to high 70's. Medical team aware of dose of Levophed and Map not meeting set goal of > 80. Has received a total of 3 liters of NS boluses this shift. Has tolerated well. CVP 2-8.\n\nGI: BS active. NO BM this shift. No c/o of abd tenderness.\n\nGU: UO very sluggish this shift. Medical team aware. Has received NS boluses as already noted. Urine cloudy dark amber.\n\nPain: Has c/o of back pain. No relief with has received MS.\n\nSocial: Daughters here early in shift. Updated on pts status by Dr. .\n\nDispo: Pts UO with cont to be monitored with boluses as ordered. Levophed cont. with goal of Map>80. Pain control with MS .\n" }, { "category": "Nursing/other", "chartdate": "2148-06-09 00:00:00.000", "description": "Report", "row_id": 1473009, "text": "MICU NSG 7A-7P\nRESP--PT CONTS ON NC 4-6L. RR 8-20, NOTED TO HAVE SHORT PERIODS OF APNEA WITH DECREASING SATS WHILE SLEEPING. LUNGS WITH DECREASED BS IN BASES.\nCARD--CONTS ON LEVO GTT, SLOWLY INC OVER SHIFT, TITRATING FOR MAP 65 OR GREATER. CONTS WITH ANASARKA. ARMS WEEPING COPIOUS AMOUNTS OF SEROUS FLUID, SOAKING THROUGH PINK PAD Q2.\nGU--U/O REMAINS MARGINAL. RECEIVED IVF BOLUS X2 WITH POOR EFFECT ON U/O.\nGI--CONTS ON TPN, TAKING MIN PO'S, HAVING DIFF SWALLOWING PILLS. NO BM'S TODAY.\nNEURO--PT ALERT, AND ORIENTED TO SELF ONLY THIS AM, THIS AFTERNOON ABLE TO SAY SHE WAS IN HOSPITAL, BUT UNSURE OF DATE.\nSOCIAL--SON IN TO VISIT, UPDATED ON PT'S CONDITION. TO DISCUSS WITH PT AND 2 DAUGHTERS REGARDING CODE STATUS DECISION.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-10 00:00:00.000", "description": "Report", "row_id": 1473010, "text": "NURSING PROGRESS NOTE:\nPT ALERT BUT NOT ALWAYS ORIENTED TO HER SURROUNDINGS. MED X 2 DURING THE NIGHT FOR GENERALIZED DISCOMFORT AND ARM PAIN. PT SLEPT OFF AND ON THROUGHOUT THE NIGHT. WHEN ASLEEP PT RR SIGNIFICANTLY SLOWS DOWN BUT O2 SAT'S HAVE REMAINED IN THE HIGH 90'S.\nREMAINS ON LEVO AND NO ATTEMPTS HAVE BEEN MADE TO WEAN IT. U/O MUCH BETTER WITH GOOD BP. PT REMAINS AFEBRILE BUT WBC IS CLIMBING.\nBOTH ARMS CONT TO WEEP LRG AMT'S OF SEROUS FLUID. PINK PADS CHG'D FREQ DURING THE NIGHT. PT CONT WITH SEVERE ANASARCA WITH INC TOTAL BODY EDEMA. PT TAKING SMALL SIPS CLEAR LIQS AND IS ABLE TO SWALLOW PILLS. PT HAS BEEN MADE A DNR. DID NOT HEAR FROM FAMILY OVERNIGHT.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-09 00:00:00.000", "description": "Report", "row_id": 1473008, "text": "NURSING PROGRESS NOTE:\nPT SLEEPING AT BEGINING OF SHIFT AND WOKE UP C/O GENERALIZED PAIN. PT MED WITH 1MG MSO4 WITH RELIEF AND FELL BACK TO SLEEP. WHEN AWAKE PT WAS ALERT AND ORIENTED. BY 0200 PT AWOKE CONFUSED AND PULLED OUT HER A LINE. PT NOT SURE WHERE SHE WAS AND THOUGHT SHE WAS GOING TO DIE. PT REASSURED SHE WAS OKAY AND SHE SETTLED DOWN. C/O PAIN AGAIN AND WAS MEDICATED WITH MSO4 WITH RELIEF. PT ALSO BEGAN COMPLAINING THAT IT WAS DIFF TO BREATH BUT HER O2 SAT'S WERE 100%. ALSO PT'S BLOOD PRESSURE BEGAN DROPPING SLOWLY TILL IT SETTLED IN THE 80'S. LEVOPHED RESTARTED ON 2 DROPS WHICH BROUGHT HER BP BACK UP TO THE ONE TEENS.\nPT'S NASAL CANULA INC TO 5L BECAUSE O2 SAT'S STARTED DROPPING TO THE HIGH 80'S.\nPT'S U/O DROPPED OFF WITH LOW BP, PT PRESENTLY RECEIVING FLUID BOLUS OF 250CC NS. REPEAT X 1.\nPT ARMS CONT TO SEEP LRG AMT'S OF SEROUS FLUID LEFT GREATER THAN THE RIGHT. PT'S COCCYX REDENED AND ABRADED, PT TURNED SIDE TO SIDE AND BACK CARE DONE.\nPT'S LUNG SOUNDS CLEAR BUT DIMINISHED AT THE BASES.\nNO STOOL AT THIS TIME, PT HAS POS BOWEL SOUNDS.\nHAVE NOT HEARD FROM FAMILY DURING THE NIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-07 00:00:00.000", "description": "Report", "row_id": 1473005, "text": "MICU NPN 7A-7P\nNeuro: AAO x 3, sometimes confused/forgetful, MAE. No obvious defecits noted.\n\nCV: Pt. remains on max dose Levofed @ 0.17 mcg/kg/min with resultant MAPs 70's. Team happy with this MAP; no plans to add other pressors or attemtp to wean this one. + generalized edema, worse in arms.\n\nResp: O2 sat on 3L NC consistently > 96%; lungs CTA upper, diminished with faint crackles lower lobes. Abg this AM showed 7.18/118/32, bicarb 19. No changes made in respiratory management.\n\nGI: + BS x 4, abd. soft, slt. distended and diffusely tender. No BM today. FIB in place. Pt. tolerating small amts. clear liquids without problems. TPN @ 47cc/hr started today for better nutritional support.\n\nGU: Foley patent, draining 10-15 cc/hr of cloudy amber urine. Cx from + for MRSA in urine.\n\nID: WBC this AM 20.8, up from yesterday. Abx regimen changed today; pt. remains on IV Vanco and Levaquin; Flagyl changed to PO and Vanco PO D/C'd. Pt. on contact precautions for presumed and + MRSA in urine.\n\nSkin: Small stage II ulcer on sacrum. Bilat arms with multiple skin tears oozing serous fluid. Dermatology recommends elevating pt.'s arms and sent a culture of fluid from pt.'s left arm, but does not think that they look any worse than yesterday. Pt. would benefit from a First-step mattress. Frequent turning in effect.\n\nSocial: Pt.'s children and grandchild all in to see her today. Very supportive.\n\nSee CareVue for further details.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-06-08 00:00:00.000", "description": "Report", "row_id": 1473006, "text": "Nursing Progress Note:\n\nNeuro: Alert and oriented. Follows commands. Able to move all extremities purposefully and equally.\n\nCV: SR did have a six beat run of V tach around 2100. Dr. made aware. No new orders. Levophed gtt infusing. Titrating to keep map >80. Have decreased gtt from .17 to 0.081.\n\nResp: On 4L/NC. O2 Sat 98-100% Lungs clear upper lobes. Crackles in the bases. Non productive cough. No c/o of SOB.\n\nGI: Tolerating clear liquids. No c/o of abdominal pain. No BM this shift.\n\nGU: UO still sluggish. Medical team aware. UO dark amber cloudy.\n\nPain: Has required ms for back pain unrelieved by .\n\nSocial: Daughters visited early in shift updated on pts condition.\n\nDispo: Will cont to monitor pts UO and maintain MAP >80.\n" }, { "category": "Nursing/other", "chartdate": "2148-06-08 00:00:00.000", "description": "Report", "row_id": 1473007, "text": "MICU NPN 7am-7pm note\nNeuro: Pt awake and alert. Oriented x3. Following commands. Purposeful movements.\n\nResp: 02via NC 3L. O2 sats 99%. LS clear upper and diminished at bases. Pt c/o some SOB while lying flat. Resolved with HOB increased. ABG 7.21/33/96/14.\n\nCV: Levophed gtt weaning to off. Goal is to keep MAP >65. CVP 5-7. Plus 3 lower extremity edema noted. NS 50 cc/hr running.\n\nGU: U/0 minimal 30-70cc/hr. Bun 61 Creatinine 1.8 today.\n\nGI: No stool this shift. rectal bag on. C-diff culture from negative. Pt receiving TPN.\n\nSkin: Pt placed on a first step mattress today. lower extremities non weeping blisters. Arms with errythema, weeping, tender to touch.\n\nID: MRSA in urine. Pt continues on Vancomycin, flagyl, and levofloxin for antibx. coverage.\n\nSocial: Daughters in to visit most of morning and early afternoon.\n\nDispo: Full Code\n\nPlan: Wean off levophed. Keep Map >65. Watch U/O.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2158-10-10 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 768024, "text": " 1:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/o ischemia, appy\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with no medical problems ?s/p appy \"with pregn\" now with\n right-sided abd pain for 2-3 days and elevated WBC\n REASON FOR THIS EXAMINATION:\n r/o ischemia, appy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CTu TUE 2:46 AM\n dissection of abdominal aorta with active extravasation of IV contrast;\n hemoperitoneum\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Right-sided abdominal pain for 2-3 days, elevated white blood cell\n count.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\n the abdomen and pelvis after the administration of IV contrast. Oral contrast\n was not administered secondary to the request of the EU and surgical house\n staffs.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a moderate hiatus hernia and\n cardiomegaly. The lung bases demonstrate mild dependent atelectasis. There is\n a ruptured infrarenal abdominal aorta aneurysm, with an intimal flap best seen\n on series #2, image #33. There is active extravasation of the IV contrast\n outside of the aortic lumen. There is a significant amount of soft tissue\n material throughout the retroperitoneal cavity, likely representing extensive\n hemoretroperitoneum. This is seen displacing the bowel anteriorly and a\n markedly distended gallbladder inferolaterally. The above described dissection\n and disruption of the abdominal aorta extends from the level of the renal\n arteries down to the aortic bifurcation. This dissection does not appear to\n extend into the iliac vessels. There are diffuse low attenuation foci within\n the liver parenchyma, likely representing a simple cyst, but too small to\n further characterize. There are multiple simple appearing cysts of both\n kidneys. The adrenal glands and major branches off of the abdominal aorta\n appear within normal limits.\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is seen within a collapsed\n urinary bladder. There is free fluid within the dependent portion of the\n pelvis. There is no evidence of free air.\n\n Bone windows demonstrate diffuse degenerative changes.\n\n Multiplanar reformatted images confirm the above findings.\n\n IMPRESSION:\n 1. Ruptured infrarenal aortic aneurysm with active extravasation of IV\n contrast into the retroperitoneum. Extensive hemoretroperitoneum, as described\n (Over)\n\n 1:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/o ischemia, appy\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n above.\n 2. Hiatal hernia.\n\n The above findings were immediately discussed with the EU and surgical house\n staff caring for the patient at the time of the examination. The patient was\n immediately transported to the operating room.\n\n\n" }, { "category": "ECG", "chartdate": "2158-10-14 00:00:00.000", "description": "Report", "row_id": 164433, "text": "Atrial fibrillation with a rapid ventricular response. Low limb lead voltage.\nInferolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.\nCompared to the previous tracing of findintgs are most likely unchanged.\n\n\n" }, { "category": "ECG", "chartdate": "2158-10-10 00:00:00.000", "description": "Report", "row_id": 164434, "text": "Sinus rhythm\nLateral ST changes are nonspecific\nBaseline artifact\nCompared to previous ECG of no change\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2158-10-09 00:00:00.000", "description": "Report", "row_id": 164435, "text": "Sinus rhythm\nleft atrial abnormality\nProbable old inferior infarct\nNo previous ECG\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2158-10-11 00:00:00.000", "description": "Report", "row_id": 1433383, "text": "Resp Care Note:\n\n\nPt cont intub on mech vent as per Carevue. Lungs ess clear. No changes made overnoc. Pt ABG stable on present vent settings. Cont mech vent support and begin to wean today as tol.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-11 00:00:00.000", "description": "Report", "row_id": 1433384, "text": "Neuro: Pt remains sedated with propofol and Fent gtts. Pt winces\nwhen turned and suctioned. Right pupil non ractive ? cataracts.\nNo spont movement of extremities noted.\n\nResp: Pt is intubated, FIO2 of 50% and peep of 10. ABG's during night\nhave been good with PO2 >100 until this morning with PO2 <100>. Pt suctioned and saline lavaged with slight brown tinged thick secretions\nsmall amt. Suctoned again for white thick scant secretions. Lungs clear upper lobes bilat and coarse lower lobes bilat. O2 sats 96% this morning.\n\nCV: Heart rate 59 to 62 most of night on Amniodarone at .5, rhythm\n1st degree AV block, some PAC's, ? 2nd degree block. MAP kept between\n68 and 75 with Neo. CVP 10 to 12.\n\nGI: ABd lg and firm. OGT to LCWS draining bilious drainage. Needing\nirrig freq during the night. Pt NPO.\n\nGU: Foley to gravity draining yel/amber urine,\n\nSKIN: Areas of bruising scattered over body, small open area. about the size of a pin head on left inner buttock towards coccyx. Duoderm\napplied.\n\nWound: Abd incision with staples oozing mod amt S/S drainage from\nlower part of incision. Dsg changed x1\n" }, { "category": "Nursing/other", "chartdate": "2158-10-11 00:00:00.000", "description": "Report", "row_id": 1433385, "text": "shift update:\n\nneuro: propofol off. cont on fentanyl decreased to 25mcg/hr for pain. alert nodding appropriate. denies pain. mae.\n\ncardiac: amio off d/t brady cardia. hr increased to 70's. nsr with frequent pac's. neo titrated to keep map>65. + pp bilaterally + pe. pt baseline per daughter. sq heparin held per Dr. . left ej line d/c'd.\n\nresp: while pt awake multiple vent changes made in attempt to stimulate pt's own breathing. currently on simv+ps, 5 of peep 18 of ps & a rate of 10. see flow sheet.\n\ngi/gu: og tube with billious drainage irrigated. + hypoactive bs. uop borderline. 250 ns bolus given x2. improved after 2nd bolus.\n\nsocial: son & daughter in to visit updates given.\n\nplan: cont to vent wean. pain management. titrate neo to keep map's <90/>70\n" }, { "category": "Nursing/other", "chartdate": "2158-10-12 00:00:00.000", "description": "Report", "row_id": 1433386, "text": "Neuro: Pt is intubated, she does follow commands, MAE, squeezes your hands upon command, wiggles toes upon command. Pt off all sedation gtts.\n\nCV: Heart rate 70's to 80's NSR with few PAC's. Neo on briefly during the night, pt received 1 fluid bolus of 250cc for low U/O and low CVP of 7. MAP 64, she responded with cvp to 12, MAP 70's and urine output picked up a bit.\n\nResp: Pt cont to be intubated on 50% FIO2 with O2 sats 96%. Lungs clear upper lobes and clear to left lower lobe, coarse right lower\nlobe. Suctioned for mod amts of thick rusty colored secretions.\n\nGI: Abd soft, distended, OGT to LCWS draining bilious drainage with faint BS upper quads only.\n\nGU: foley to gravity, draining amber urine\n\nPain: Pt having pain, when asked she nods her head yes and when she is turned she grimaces, getting Dilaudid IV with fair effect.\n\nWound: Midline incision with staples in tact, scant S/S drainage from\nlower part of staple line.\n\nPlan: Try and wean from vent today.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-10-10 00:00:00.000", "description": "Report", "row_id": 1433382, "text": "admission note.\nshift update:\n\nneuro: opens eyes to speech. unable to follow commands. pearla. cont on propofol & fentanyl. multiple boluses of fentanyl/versed given for sedation. turned and repositioned in afternoon.\n\ncardiac: nsr. neo/labetalol titrated to keep map <90 or >70. vascular team attempted to float swan. unable d/t inability to inflate balloon and pass catherter into ra/rv, when able to pass catherter pt. having lots of ectopy svt/afib, requiring cardiovertion at 70j x1. converted to nsr. started on amio 150mg bolus given then 1mg/hr gtt. no further ectopy noted, although pt. appears to be in some form of av block, pr intervals varying from .20-.28, strip posted in bedside book. Sicu team in and placing tlc through r ij cordis for increase access purposes, pcxray obtained, line ok. sicu team to attempt swan placement in am. 4u prbc/5pk plts/2u ffp given. k+/ca repleated. Pt. currently being r/o with ck's, needs 3rd set tonight.\n\nresp: lungs clear. suctioned x1 for small amt blood tinged secreations. abg's showing acidosis. several vent changes made. currently on simv, 10 of peep, 50% fio2 & rate of 14.\n\ngi/gu: ngt removed. og inserted-> clws. small amt dark red drainage noted. uop borderline 14-40cc/hr. initially blood tinged. currently amber colored. bld. sugar treated with s.s. insulin. extremely hypo bs thru-out.\n\nsocial: family in to visit. Dr. spoke with family.\n\nplan: swan placement in am. cont. with current gtt's, monitor hct & coags closely, cont. to r/o pt with ck's.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-14 00:00:00.000", "description": "Report", "row_id": 1433393, "text": "nsg note\nSEE CAREVUE FOR SPECIFICS.\n\nNEURO-A+OX2. PT FORGETFUL AT TIMES. PT , BUT OCC PULLING AT O2 AND LINES.\n\nCV-LOW GRADE TEMP. PT WENT IN TO RAPID AFIB, RATE 150 AND SBP DOWN TO 70 THIS AM. TEAM AWARE AND IN TO ASSESS. ESMOLOL GIVEN BY MD WITHOUT EFFECT. ATTEMPTED ELECTRIC CARDIOVERSION X2 WIHTOUT EFFECT. AMIODOARONE BOLUS GIVEN AND GTT STARTED. PT CONVERTED TO NSR AND HAS REMAINED IN NSR SINCE. AMIO GTT CON'T. PT ON NEO FOR SHORT PERIOD UNTIL CONVERTED TO NSR. SBP THEN INCREASED AND NEO WEANED OFF. CPK'S BEING CYCLED. EKG DONE. SBP THIS PM UP TO 150'S. TEAM AWARE. EXTRA 1 TIME DOSE OF LOPRESSOR GIVEN WITH + EFFECT. SKIN W+D. +PP. FEET REMAIN EDEMATOUS. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 97% ON 70% FACE MASK. LS CLEAR, DECREASED AT BILAT BASES. C+DB ENC. IS ATTEMPTED, BUT PT WITH POOR TECH. NARD NOTED.\n\nGI-ABD SOFT, NT/ND. +BS. TOL SM SIPS H2O WITHOUT INCIDENT. DENIES N/V. ABD DSG C/D/I.\n\nGU-VOIDNG VIA FOLEY. U/O LOW AT TIMES. TEAM AWARE. LASIX GIVEN. AWAITING EFFECT.\n\nCOMFORT-DILAUDID PRN WITH ADEQ EFFECT.\n\nSKIN-SKIN INTACT. MULTI AREAS OF ECCHYMOSIS NOTED, ESP ARMS.\n\nPLAN-CON'T WIHT CURRENT PLAN. AMIO GTT. 3RD SET CPK'S DUE AT 1AM. ASSESS PAIN. PULM HYGIENE.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-15 00:00:00.000", "description": "Report", "row_id": 1433394, "text": " - \nNursing Progress Note 1900-0730\n\nS/O\nNEURO: Confused to location, events; picked at lines/tubes/drains -> after severeal reminders about her own safety, restrained hands with soft wrist restraints. Cooperative with care. Denies pain.\n\nCV: Hydralazine 5 mg IV given x 1 for SBP > 140 with transient efect. BP increases with any activity. Remains in NSR, receiving Lopressor.\nAll extremities edematous.\n\nRESP: LS diminished in bases but improving as awakened this a.m. On cool mist and nc, mist d/c'd and remains on O2 @ 4 LPM. No crackles, no wheezes.\n\nGI: BS positive RLQ, RUQ, LLQ. Abd drsg d&i with old bldy drng. C/O hunger.\n\nFEN: K+ 3.3 -> repleted with 40 mEq's IV; Mg 2+ 1.8 -> repleted with 2 Gm.\n\nGU: Making urine via foley.\n\nSKIN: Abd on right of wound is red, raw -> A & D applied; All extremities ecchymotic. x inch blister on LLQ.\n\nA/P\n with MD's re: changing to oral med to wean off amiodarone gtt.\nMoniter comfort level. Fragile skin care regimen.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-15 00:00:00.000", "description": "Report", "row_id": 1433395, "text": "nsg note\nSEE CAREVUE FOR SPECIFICS.\n\nNEURO-PT ALERT, ORIENTED X . MAE. NO DEFICITS NOTED.\n\nCV-AFEBRILE. HR 70'S, NSR, NO ECTOPY. PT STARTED ON PO AMIODORONE AND GTT TURNED OFF. SBP 120-140. LOPRESSOR CHANGED TO PO AND HYDRALAZINE STARTED TO KEEP SBP <140. SKIN W+D. +PP. FEET REMAIN EDEMATOUS.\n\nRESP-O2 SAT 95-98% 4LNC. LS CLEAR, DECREASED AT BILAT BASES. C+DB ENC. RR 10-20'S, NARD NOTED.\n\nGI-ABD SOFT, NT/ND. +BS. BM X1. TOL SM AMT CL LIQS WITHOUT N/V. INCISION WITH STAPLES, OTA WITH SL ECCHYMOSIS AT EDGES.\n\nGU-LASIX GIVEN THIS AM WITH + DIURESIS. U/O NOW TRENDING DOWN. WILL NOTIFY HO. URINE VIA FOLEY CLEAR AMBER COLORED.\n\nACT-OOB TO CHAIR WITH 2 ASSIST FOR MOST OF SHIFT. TOL WELL.\n\nCOMFORT-DILAUDID X 1 WITH ADEQ STATED EFFECT.\n\nSKIN-SKIN INTACT. MULIT AREAS OF ECCHYMOSIS ESP BILAT ARMS.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. OOB AS TOL. PULM HYGIENE. TO VICU WHEN BED AVAIL.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-16 00:00:00.000", "description": "Report", "row_id": 1433396, "text": "focus; output\ndata: u/o 30-50/hr. lasix 10 mg iv x 1 with good response. k 3.5, repleted with kcl 40 meq/100 cc over 4 hrs.\n\n" }, { "category": "Nursing/other", "chartdate": "2158-10-13 00:00:00.000", "description": "Report", "row_id": 1433390, "text": ", 0700-1000\n\nNeuro: Awake, alert. Conversing appropriately post-extubation. MAE, lower extremities slightly weaker than upper extremities.\n\nCV: HR 80-100, NSR w/rare unifocal PVC. BP 140-160's/50-70 w/MAP 90-110 via right radial A-line. Lopressor 5mg IV q6hours ordered and initiated this am. Peripheral pulses palpable.\n\nResp: Extubated to FM this am. RR 22-28, non-labored. Coarse lung sounds, expectorating blood-tinged secretions. O2 sat 95-97%.\n\nGI: OGT d/c'd this am. Faint, hypoactive bowel sounds. Abd. soft, non-tender, slight distention. Remains NPO.\n\nGU: Foley to BSD draining clear, yellow urine. Diuresing from am Lasix. Rpt Lasix dose due at 1200 today. Last K 4.5\n\nInteg: Abd incision clean. Staples intact. Scant amt. sero-. draingage noted. DSD reapplied. Diffuse eccymosis particularly on both arms. DSD on left wrist d/t sero-sang drainage. Generalized edema (wt 64.2kg today). Compression sleeves on. Right radial A-line intact. Right IJ introducer/multi-lumen port to be changed today.\n\nSocial: Family in to visit this am. Pt. status reviewed w/MD. Questions/concerns addressed.\n\nPlan to transfer to SICU today.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-13 00:00:00.000", "description": "Report", "row_id": 1433391, "text": "Nursing note:\nTransferred to SICU from CSRU at 1230.\nNeuro: A/0x 2, poor short term memory - asking same ?s , but appropriate in conversation. PERLA. Following commands.\n\nCV: Tmax 99s, SBP 120-140s, ST 80-100, no ectopy. Palpable pulses bilat. 2+ pedal edema. No cardiac c/o's. wearing pboots. Triple lumen catheter changed over wire. +placement via CXR.\n\nRESP: Lung sounds coarse, wearing 50% FM, encouraged to cough and deep breathe w/effect and using I/S w/encouragement. Sats 95-99%.\n\nGI: +very faint hypo BS, abdomen softly distended, DSD intact w/minimal staining noted. NPO. no n/v.\n\nGU: Foley patent large amount clear yellow urine. Large diuresis s/p 40mg IV Lasix.\n\nACT: Turn/repositioned frequently.\n\nSKIN: Douderm to L. buttock removed, area slightly reddened, no breakdown noted. Bilat. arms and legs w/dark red/purple areas of ecchymosis - RN these are d/t old IV sites.\n\nComfort: Denies incisional pain.\n\nA: Stable s/p AAA repair w/large blood loss and fluid requirements.\nP: Cont. to monitor hemodynamic status, comfort, aggressive pulm. hygeine.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-14 00:00:00.000", "description": "Report", "row_id": 1433392, "text": "CONDITION UPDATE:\nD/A: T MAX 100\n\nNEURO: PT VERY CONFUSED AT TIMES, PICKING AND PULLING AT TUBES/LINES. DENIES PAIN. LONG TERM MEMORY INTACT, STM POOR. MAE, PERL, VOICE IS HOARSE, SPEECH IS CLEAR.\n\nCV: HR 80'S-90'S NSR. ABP 114-147/60'S. + 3 PITTING EDEMA LE'S WITH + PPP UNDER EDEMA. ALINE WAS D/ BY PT, NEW LINE PLACED.\n\nRESP: LS CLEAR, PT FOLLOWS ALL COMMANDS TO COUGH AND DEEP BREATH. ABG CONCERNING IN EVENING WITH PAO2 64. FIO2 INCREASED TO 100% ON HUMIDIFIED MASK, PAO2 97!\n\nGI: PT REQUESTING TO DRINK. + BS, NPO, SMALL SMEAR OF STOOL. ABD INCISION WITH SMALL AMOUNT SERO-SANG DRG.\n\nGU: FOLEY-BSD WITH CLEAR AMBER URINE.\n\nR: MENTAL STATUS WAXES AND WANES, VSS, LOW GRADE TEMP, RESP STATUS IMPROVED.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. PT .\n" }, { "category": "Nursing/other", "chartdate": "2158-10-12 00:00:00.000", "description": "Report", "row_id": 1433387, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: CONT. TO FOLLOW COMMANDS, AND MOVE ALL EXTREMITIES TO COMMAND. DENIES PAIN MOST OF SHIFT, BUT MEDICATED WITH DILAUDID .5MG IVP X1. OOB TO CHAIR WITH MAX ASSIST X2, NOT VERY STEADY OR ABLE TO BEAR MUCH WEIGHT ON LEGS. PEERL. BILT. SOFT WRIST RESTRAINTS ON WHEN FAMILY OUT OF ROOM, BUT HANDS LEFT UNDONE WHEN FAMILY AROUND.\nCARDIAC: CONT. TO BE IN NSR WITH NO ECTOPY. SYS B/P 100-150'S WITH MAP'S 60-100, REMAINS OFF ALL PRESSORS. MAINTAINCE IVF DECREASED TO KVO. + BPPP. KEFZOL D/C'D. R IJ CORDIS AND TLC INTACT.\nRESP: BS CONT. TO BE DIMINISHED IN R LOWER LUNG. YESTERDAY CXRAY SHOWING BILT. PL. EFFUSSIONS. ATTEMPTED THIS AM TO WEAN VENT TO PRESSURE SUPPORT ONLY, ABG SHOWING RESP ACIDOSIS, VENT ADJUSTED. AFTER RECEIVING IVP LASIX AGAIN ATTEMPTED TO WEAN VENT TO IPS WITH IMPROVING ABG'S. PEEP DECREASED TO 5 FROM 8 AND REPEAT ABG EXCELLENT. SUCTIONING FOR SCANT AMT. OF WHITISH SECREATIONS. ETT ROTATED.\nGI/GU: HOURLY URINES FOLLOWING TO <10CC/HR, GIVEN 10MG IVP LASIX WITH GREAT RESULTS, INITIALLY SEDIMENT NOTICED AND CLEARING AS DAY PROGRESSED. - BS THRU-OUT, OGT->LCWSX DRAINING SM. BILIOUS SECREATIONS. BS CONT. TO BE MONITORED BUT NOT TREATED.\nSKIN: ABD INCISION DRAINING SM. AMT OF BLOODY DRAINAGE NOTED, DSG CHANGED. DUODERM ON BUTTUCKS INTACT. LOTS OF PETICHI NOTED ON ALL EXTREMITIES. BILT. ARM BRUSING, ELEVATED ON PILLOWS.\nSOCIAL: DAUGHTER AND SON INTO VISIT UPDATE GIVEN.\nPLAN: CONT. WITH DIURESIS, IF HOURLY URINES CONT. TO DROP AGAIN GIVEN ADDITIONAL 10MG IVP LASIX PER DR. . CONT. WITH AGGRESSIVE PULM. TOILETING, PLAN NOT TO EXTUBATE PER VASCULAR SERVICE TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2158-10-12 00:00:00.000", "description": "Report", "row_id": 1433388, "text": "3PM-7PM UPDATE\nNEURO: PT ALERT. ABLE TO FOLLOW COMMANDS. MAE SPONTANEOUSLY. UNABLE TO ASSESS ORIENATATION D/T ET TUBE.\n\nCV: PT REMAINS NSR, NO ECTOPY NOTED. HR 80-90'S. MAP 70-80'S. SBP 110-120'S. K 3.9 -> TREATED WITH 40 MEQ KCL. PP BY DOPPLER.\n\nRESP: LS CLEAR. PT SUCTIONED FOR SCANT WHITE THIN SPUTUM. PT WEANED TO 40 % CPAP WITH 5 IPS AND 5 PEEP (ABG PENDING) TV 400'S. RR 12-20.\n\nGI/GU: PT + HYPOACTIVE BS. OGT TO SUCTION DRAINING SCANT AMOUNT OF BILLOUS DRAINAGE. FOLEY TO GRAVITY DRAINING CLEAR YELLOW URINE. DIURESING WELL FROM LASIX\n\nACTIVITY/COMFORT: PT OOB TO CHAIR THIS AFTERNOON WITH 2 PERSON ASSSIST. PAIN CONTROL WITH DILUADID IV.\n\nPLAN: CONTINUE PS VENTIALTION OVERNIGHT, ? EXTUBATE TOMORROW, MONITOR LABS, PULM TOLEIT, PAIN CONTROL\n" }, { "category": "Nursing/other", "chartdate": "2158-10-13 00:00:00.000", "description": "Report", "row_id": 1433389, "text": "Neuro: Pt responds to her name, follows commands, moving upper extremities weakly, and barely can move lower extremities.\n\nCV: Heart rate 90's to 80's NSR with MAP at timess 90 to 100 when\nshe is awake and stimulated with company.\n\nRESP: Pt cont to be intubated and remained on CPAP all night with\no2 sats 96%, lungs clear upper lobes and dim lower. Suctioned\nbloody secretions, mod amt x2 during the night.Mod amt of oral bloody secretions, air leak x2.\n\nGI: Abd softly distended with faint BS upper quads only. OGT with\nthick bilious drainage.\n\nGU: Foley to gravity draining yel, cloudy/sed urine. lasix 10mg given\nat 6:30.\n\nPLAN: ? extubate today\n" } ]